Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): an analysis of 1,584 LASH cases.

OBJECTIVE: The objective of this research was to identify the rate of unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH) and describe the therapy regime. METHODS: The research is based on a retrospective chart analysis of patients undergoing a simple hysterectomy in the gynecological endoscopy department of a general hospital in Germany. RESULTS: 2,577 simple hysterectomies conducted between March 2005 and March 2010 were sub-classified in different types of hysterectomies (vaginal-, abdominal-, total-, abdominal supracervical hysterectomy, LAVH, and LASH). This study focuses on the LASH sub-group of 1,584 patients and does not make any comparisons to other operative approaches. Out of the 1,584 patients, 87.8 % (n = 1,391) received preoperative screening to exclude dysplasia or malignancy based on the policy of the German Association for gynecology and obstetrics (DGGG). The screening includes cytology (Pap-smear) and preoperative ultrasound of the uterus or dilatation and curettage (d&c). Unexpected malignancies were found in 0.25 % (n = 4) of the patients pre-screened according to DGGG protocol. Out of the four malign patients, two had endometrial cancer. Two patients had leiomyosarcoma. CONCLUSION: The study shows that there is a small probability of unexpected malignancies even in correctly pre-screened patients for LASH procedures. Yet in the short-term (28-52 months), malign patients remain recurrence free after treatment. LASH is therefore a good procedure for assumed benign disease.

Developing an interdisciplinary consultation service for vulvar disorders.

BACKGROUND: Diseases of the vulva often cause severe impairment and long-term problems for the affected women. Adequate treatment requires expert knowledge on the part of treating dermatologists and gynecologists. This was the reason for the initiation of an interdisciplinary consultation service for vulvar diseases at the University Hospital of Lübeck. PATIENTS AND METHODS: Over a period of 2½ years, 208 patients were seen in the new consultation service. Cases were classified as inflammatory diseases, neoplastic diseases, infectious diseases, vulvodynia, or genodermatoses. The effectiveness of treatment was documented by photography, biopsy and - whenever applicable - a quality of life assessment using the Dermatology Life Quality Index (DLQI). RESULTS: Inflammatory dermatoses were diagnosed in 133 patients and neoplas-tic diseases in 32 patients. Infection was diagnosed in 25 patients, vulvodynia in 8, genodermatoses in 3 and other diseases in 7. The DLQI was assessed in 140 patients. Of these, 55 patients had a DLQI > 10 (0-30), indicating severe or extreme impairment of quality of life. A follow-up DLQI was collected in 81 patients, showing a significant improvement. CONCLUSIONS: The patients and both hospital facilities benefitted from the interdisciplinary consultation service. The initial high costs in terms of medical staff and time was compensated by the development of diagnostic and treatment algorithms. Overall, the concept received positive feedback from patients and medical staff members.

Primary metastasized extraskeletal Ewing sarcoma of the vulva: report of a case and review of the literature.

PURPOSE: Ewing's sarcoma (ES) and primitive neuroectodermal tumor (PNET) are closely related malignant neoplasms, usually affecting the skeletal system. Extraosseous ES/PNETs are uncommon, with occasional reports of tumors affecting the genitourinary tract. Only few cases of primary vulvar Ewing's sarcoma/PNET have previously been reported. METHODS: We present a patient with primary vulvar Ewing's sarcoma with pulmonary metastasis who presented at the Department of Gynecology and Obstetrics, University of Schleswig-Holstein, Campus Luebeck. RESULTS: The present report is the third case of a primary vulvar Ewing's sarcoma and the first constellation with pulmonary metastasis at diagnosis in the current literature. We present the diagnostic and therapeutic management including surgery, chemotherapy and radiation. CONCLUSION: The treatment of the Ewing's sarcomas and PNETs requires a multidisciplinary systemic approach. Despite its rarity, the differential diagnosis of vulvar sarcoma must be considered in young women.

Laparoscopic supracervical hysterectomy (LASH), a retrospective study of 1,584 cases regarding intra- and perioperative complications.

OBJECTIVE: The main interest of this study was to assess the rate of intraoperative and perioperative complications of laparoscopic supracervical hysterectomy (LASH) in a teaching hospital. METHODS: A retrospective analysis of 1,584 laparoscopic assisted hysterectomies between 2005 and 2010 by different surgeons. RESULTS: In 2,577 patients undergoing simple hysterectomy, an indication for LASH was present in 1,584 cases. Indications were uterine myomas (71.6%), dysfunctional uterine bleeding (12.6%), suspicion of adenomyosis uteri (8.9%), descensus uteri (2.8%), dysmenorrhea (2.8%), hysterectomy on demand (1.2%) and benign hyperplasia of the endometrium (0.2%). Mean duration of the procedure was 76.5 ± 33.4 min (95% CI, ± 1.66). The average age of patients was 45.9 ± 5.4 years (95% CI, ± 0.27). Mean body mass index (BMI) was 25.3 ± 4.9 (95% CI, ± 0.24). Adhesiolysis due to earlier surgery had to be performed in 190 (12%) cases. The total complication rate was 1.07%. The total conversion rate to laparotomy was 0.88%. The rate of conversion after laparoscopic assessment of the situs was 0.57%. In five cases, conversion to laparotomy was necessary due to intraoperative complications (0.32%). On the whole, six bleedings (0.38%), four bladder injuries (0.25%), three intestinal injuries (0.19%), one ureter injury (0.06%), one injury of the epigastric vein (0.06%) and two omental incarcerations (0.13%) occurred. CONCLUSION: In this retrospective analysis, the rate of complications for LASH was very low in a hospital of standard care and residency. LASH has to be considered as a minimally invasive method with a low perioperative morbidity to treat benign uterine pathologies even in a teaching setting and should therefore be the method of choice if the cervix can be preserved.

Laparoscopic-assisted vaginal hysterectomy with and without laparoscopic transsection of the uterine artery: an analysis of 1,255 cases.

INTRODUCTION: To evaluate the operative outcomes of patients managed by laparoscopic-assisted vaginal hysterectomy (LAVH) with and without laparoscopic transsection of the uterine artery for benign gynaecologic diseases. PATIENTS AND METHODS: A retrospective analysis of 1,255 women from two different centers undergoing hysterectomy between 1998 and 2009 with benign indications is presented. 856 patients were treated by LAVH type I (vaginal transsection of the uterine artery) and 399 patients by LAVH type II (laparoscopic transsection of the uterine artery). Operative outcomes, intraoperative and postoperative complications, as well as laparoconversion rates were the main objectives of the study. RESULTS: Median operative time was similar between LAVH type I and II (136 vs. 126 min, respectively, P = NS). Intraoperative complication rate was not significantly different between the two groups of the study (LAVH type I: 1.5% vs. LAVH type II: 1.26%, respectively, P = NS). The injury of the urinary tract, especially of the bladder, was the most common intraoperative complication for both the groups of the study. Laparoconversion rate was similar in LAVH type I and II (0.5 vs. 0.35%, respectively, P = NS), while postoperative complications were significantly higher in LAVH type I (2.25%) compared to LAVH type II (1.16%), mainly because of postoperative vaginal and intrabdominal haemorrhage in the group of the LAVH type I. CONCLUSION: LAVH with laparoscopic transsection of the uterine artery is an effective and safe technique with less postoperative complication compared to LAVH with vaginal transsection of the uterine vessels.

[Significance of laparoscopy in gynaecological oncology]. / Stellenwert der Laparoskopie in der gynakologischen Onkologie.

By now laparoscopy has become an established access route in gynaecological surgery. It took many years to get to this stage for various obstacles had to be overcome. In the end, it was the low intra- and postoperative complication rates together with the rapid reconvalescence of the patients and their wish to be quickly discharged from hospital which led to an unstoppable diffusion of the method. With the increased use of the procedure and the expertise of the surgeons, it entered the field of gynaecological oncology and met similar reservations. Once again the same convincing advantages helped overcome the resistance. Thus, laparoscopic surgical procedures have secured a place in the treatment of corpus and cervical carcinomas, as their surgical safety has been proved. The aim of future examinations should be the proof of non-inferiority compared to the open techniques because the advantages of the laparoscopic procedure have been sufficiently proved. Regardless of the required proof, the method is rapidly expanding with robot-assisted procedures, while surgeons develop exenterative techniques.

Immunohistochemical workup of sentinel nodes in endometrial cancer improves diagnostic accuracy.

OBJECTIVE: The purpose of this study was to examine the effect of immunohistochemical (IHC) staining of sentinel (SLN) and non sentinel lymph nodes (NSLN) on the detection of additional metastases in patients with endometrial cancer. PATIENTS AND METHODS: Between April 2004 and March 2006, 25 patients with endometrial cancer were operated on. A new method for labelling SLNs with Patent Blue(R) was used. One additional slice was cut out of each lymph node and immunohistochemically stained (IHC). Sentinel and NSLN nodes were re-evaluated. RESULTS: 673 lymph nodes from 21 patients were available for re-evaluation. With IHC staining significantly more metastases were detected compared to H&E staining. Though more patients with metastases were discovered this was not significant on the basis of affected SLNs or NSLNs. In the conventional evaluation 7 metastases were found in 3 patients. Applying re-evaluation and IHC 6 additional metastases in 5 patients were detected. These additional metastases were evenly distributed among the pelvic and para-aortic area, and among the SLNs or NSLNs. This had an impact on the diagnostic accuracy of the sentinel concept. Sensitivity reduced from 66.7% to 33.3% and the negative predictive value (NPV) fell from 94.7% to 79.0% only if the NSLNs were additionally IHC stained. On the contrary, if the SLNs were also IHC stained, the sensitivity rose to 83.3%, the NPV rose to 93.8%. CONCLUSION: Our results indicate that additional immunohistochemistry staining of one additional block of SLNs improves the validity of sensitivity and the NPV in the sentinel concept.

Multicenter validation study of the sentinel lymph node concept in cervical cancer: AGO Study Group.

PURPOSE: Single-institution case series have demonstrated the feasibility of the sentinel concept in cervical cancer. However, the diagnostic accuracy remains to be validated. We evaluated detection rate and diagnostic accuracy to predict the histopathologic pelvic nodal status in patients with cervical cancer of all stages. PATIENTS AND METHODS: In a hypothesis-based, prospective, multicenter cohort study, patients underwent lymph node detection after labeling with technetium, patent blue, or both. After systematic pelvic and, if indicated, para-aortic node dissection, all lymph nodes were histopathologically examined. Detection rate, sensitivity, and negative predictive value (NPV) were calculated. RESULTS: According to the protocol, 590 patients were eligible. Detection rate of pelvic sentinel nodes was 88.6% (95% CI, 85.8% to 91.1%) and was significantly higher for the combination of technetium and patent blue (93.5%; 95% CI, 90.3% to 96.0%). Of 106 patients with pelvic lymph node metastases, 82 had pelvic sentinel node metastases. The overall sensitivity was 77.4% (95% CI, 68.2% to 85.0%), which was lower than 90%, the predefined noninferiority margin (P < .001). Sensitivity in women with tumors

Laparoscopic management of early primary omental pregnancy.

OBJECTIVE: To describe the successful laparoscopic management of an omental pregnancy. DESIGN: Case report. SETTING: University of Schleswig-Holstein, Campus Luebeck, Department of Gynecology and Obstetrics. PATIENT(S): A 25-year-old patient with an omental pregnancy. INTERVENTION(S): Laparoscopic partial omentectomy. MAIN OUTCOME MEASURE(S): Successful laparoscopic management of an omental pregnancy. RESULT(S): A 25-year-old woman reported having abdominal pain. Her urine pregnancy test was positive. She had been using an intrauterine copper device for a period of 2.5 years. Gynecologic examination revealed normal results, in the uterus and fallopian tubes especially, where no signs of pregnancy were found through clinical and sonographic examination. Because the patient had had increasing pain, a laparoscopy was performed. There was approximately 500 mL of dark blood found in the cul de sac. The uterus and fallopian tubes appeared normal and without any signs of pregnancy. However, there was a cavity detected in the omentum majus. A partial omentectomy then was performed laparoscopically. An omental pregnancy was confirmed by beta-hCG-positive trophoblast cells in the omentum majus. CONCLUSION(S): Omental pregnancy can be rather difficult to identify. If there is no evidence of tubal pregnancy, laparoscopy may help to confirm the diagnosis of omental pregnancy and simultaneously offer minimal invasive therapy.

Relative expression of 1,25-dihydroxyvitamin D3 receptor, vitamin D 1 alpha-hydroxylase, vitamin D 24-hydroxylase, and vitamin D 25-hydroxylase in endometriosis and gynecologic cancers.

The authors demonstrate expression of the vitamin D receptor (VDR) and its hydroxylases in the endometrium and ovaries of women with and without endometriosis and endometrial or ovarian cancer. Immunohistochemistry showed strong staining of the VDR in endometriosis and endometrial cancer, with the most intense staining in epithelial cells. The VDR mRNA was significantly increased in patients with endometrial and ovarian cancer compared to the control group. There was a significantly higher 1 alpha-hydroxylase expression in the endometrium of patients with endometriosis compared to healthy controls. The observed differences in VDR and 1 alpha -hydroxylase mRNA levels were maintained at the protein level. The authors found no differences in 25-OH vitamin D levels between the serum of patients with endometriosis (25.7 +/- 2.1 ng/mL, n = 46) and healthy controls (22.6 +/- 2.0 ng/mL, n = 33, P = .31). They hypothesize that vitamin D might influence the local activity of immune cells and cytokines thought to play important pathogenic roles in the development and maintenance of endometriosis.

HPV16-E6 mRNA is superior to cytokeratin 19 mRNA as a molecular marker for the detection of disseminated tumour cells in sentinel lymph nodes of patients with cervical cancer by quantitative reverse-transcription PCR.

About 10-15% of patients with cervical cancer suffer from recurrence despite histologically negative lymph nodes (pN0). Occult micrometastases or small tumour cell clusters may contribute to disease outcome. The aim of this study was to compare at the RNA level 2 known tumour-associated genes, HPV16-E6 and cytokeratin 19 (CK19), as molecular markers for the detection of disseminated tumour cells. Real-time reverse transcription PCR technology was used to quantify gene expression in histologically positive and negative sentinel lymph nodes (SLN) from 70 patients with cervical cancer. Lymph nodes from noncancer patients were used as controls. Calculated copy numbers were normalised to the geometric average of the most stable housekeeping genes. We observed a good correlation (R = 0.915) between the expression of both markers in SLN with histologically confirmed metastases. However, marker gene expression differed considerably in histologically negative nodes: CK19 transcripts were detected in 90 of 112 SLN (80.4%), whereas only 38 nodes (33.9%) were positive for HPV16 E6 mRNA. In particular, 62 of 74 SLN, which were negative by histology, and HPV16 E6 mRNA expressed CK19 mRNA. Moreover, 8 of 10 lymph nodes from noncancer patients expressed CK19 mRNA. Systematic errors due to RNA degradation or incomplete cDNA could be ruled out. It is concluded that HPV16 E6 mRNA is more specific and more sensitive for the detection of tumour cells in SLN than CK19 mRNA. The specificity of CK19 is limited because of low level expression in uninvolved pelvic lymph nodes.

New developments in the use of peptide gonadotropin-releasing hormone antagonists versus agonists.

Gonadotropin-releasing hormone (GnRH) stimulates the pituitary secretion of both luteinising hormone (LH) and follicle-stimulating hormone (FSH), and thus controls the hormonal and reproductive functions of the gonads. The blockade of the effects of GnRH may be sought for a variety of reasons; for example, to control premature LH surges and to reduce the cancellation rate with the aim of improving the pregnancy rate per treatment cycle or in the treatment of sex hormone-dependent disorders. Selective blockade of LH/FSH secretion and subsequent chemical castration have previously been achieved by desensitising the pituitary to continuously administered GnRH or by giving long-acting GnRH agonists. GnRH analogues are indicated for clinical situations in which the suppression of endogenous gonadotropins (precocious puberty, contraception and controlled ovarian hyperstimulation) or sexual steroids (endometriosis, prostate hyperplasia, cancer and uterine fibroids) is desired. The immediate suppression of the pituitary that is achieved by GnRH antagonists without an initial stimulatory effect is the main advantage of these compounds over the agonists. GnRH antagonists have been developed for clinical use with acceptable pharmacokinetic, safety and commercial profiles. In assisted reproduction, these compounds seem to be as effective as established therapy, but with shorter treatment times, less use of gonadotropic hormones, improved patient acceptance, and fewer follicles and oocytes. All of the current indications for GnRH agonist desensitisation may prove to be indications for a GnRH antagonist, including endometriosis, leiomyoma and breast cancer in women, benign prostatic hypertrophy and prostatic carcinoma in men, and central precocious puberty in children. However, the best clinical evidence has been in assisted reproduction and prostate cancer.