Tumor free distance from serosa and survival rates of endometrial cancer patients: A meta-analysis.

Myometrial invasion and its extent have been directly associated with the risk of relapse as well as the overall survival of endometrial cancer patients. Tumor free distance from the serosal surface of the uterine wall has been investigated the last years by several studies, however, to date, its importance remains unknown. The present meta-analysis is based on a systematic search of the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases and has been designed according to the PRISMA guidelines. Nine studies were included in the present systematic review that recruited pathology slides from 1,598 endometrial cancer patients and their meta-analysis indicated that TFD was significantly associated with the progression free survival of patients with endometrial cancer (OR 0.36, 95% CI 0.20, 0.65). The disease specific survival was not affected by the TFD (OR 0.30, 95% CI 0.09, 1.01). Sensitivity analyses revealed, however, that both the progression free and overall survival rates were associated with TFD. Significant discrepancies were observed in terms of histological subtypes and stage of the disease among included patients, hence, the actual importance of TFD in specific subgroups remains unknown. Future studies must evaluate the importance of this pathology marker particularly in patients with endometrioid subtypes and early-stage disease, as it is believed that in this group its importance will be more predictive as it will not be skewed by the presence of more important factors such as more aggressive histology and advanced stage disease.

Pre-Operative Neutrophil-to-Lymphocyte Ratio as a Predictor of Post-Operative Infectious Morbidity in Gynecologic Oncology Patients.

Background: Neutrophil-to-lymphocyte ratio (NLR) has been described as a predictor of progression-free and overall survival, and in the field of peri-operative care it seems to be a factor that can help discriminate patients at risk of developing post-operative complications. In the present study we sought to determine whether NLR is useful as a biomarker in predictive models that aim to identify patients with gynecologic cancer undergoing surgery at risk of developing post-operative infectious morbidity. Patients and Methods: We designed a prospective cohort study that enrolled 208 patients with gynecologic cancer. Post-operative infectious morbidity was evaluated based on a 30-day follow-up interval from the procedure. Results: Forty-three patients (20.5%) developed post-operative infectious morbidity. Using an optimal cutoff value of 1.7 for the pre-operative NLR we observed that the sensitivity of the biomarker was 76.7% and the specificity 73.3% with a produced area under the curve of 0.760 (95% confidence interval [CI], 0.680-0.839). Univariable logistic regression indicated that NLR is a predictor of post-operative morbidity. Cox regression analysis revealed that NLR was the only factor that was associated with the timing of infectious morbidity (hazard ratio [HR], 1.339; 95% CI, 1.180-1.519; p < 0.001). Using random forest analysis and decision trees we achieved a diagnostic accuracy of the predictive model that exceeded 90%. Conclusions: Neutrophil-to-lymphocyte ratio may be a factor that could potentially help evaluate the risk of post-operative morbidity in patients with gynecologic cancer.

Time to full effect, following treatment with combined oral contraceptives (cyclic versus continuous administration) in patients with endometriosis after laparoscopic surgery: a prospective cohort study.

The risk of recurrence after surgery is a major problem in women who are suffering from endometriosis. The prescription oral contraceptives (OCs) in the treatment of endometriosis-related pain, in women who do not desire fertility, is still controversial. The aim of this prospective cohort study is to evaluate the time until the reduction in the mean intensity of dysmenorrhoea and deep dyspareunia takes effect, for patients who use combined OCs in the accepted cyclic manner, versus in the continuous fashion as after the laparoscopic excision of endometriosis. A total of 28 patients diagnosed with endometriosis who underwent surgical treatment were offered at least a 12 months course of oral contraceptives. The intensity of both symptoms was reduced at the end of observational period in both groups. The use of continuous OCs (11 patients) was associated with a more pronounced reduction in the mean intensity of dyspareunia and dysmenorrhoea at 9 (p = 0.004) and 6 (p = 0.003) months respectively as compared to the cyclic group (17 patients).

Identifiable Risk Factors for Lymph Node Metastases in Grade 1 Endometrial Carcinoma.

OBJECTIVE: The aim of this study was to evaluate the clinicopathological features related to lymph node metastases in grade 1 endometrial carcinomas. MATERIALS AND METHODS: Five hundred ninety-nine cases of endometrial carcinoma treated with total hysterectomy bilateral salpingo-oophorectomy and pelvic lyphadenectomy between 2001 and 2015 were retrieved from the pathology files of IASO Women's Hospital, Athens, Greece. Of these, 345 were grade 1 endometrioid carcinomas and were included in the study. Features such as the age of the patients, the stage, the location, and size of the tumors, as well as the existence of microcystic, elongated, and fragmented pattern invasion or lymph vascular space invasion, were estimated. RESULTS: In our cohort of endometrial carcinomas, features related to an increased risk of lymph node metastases were stages IB or higher; the location of the tumor in the lower uterine segment; the identification of microcystic, elongated, and fragmented pattern of invasion; and the existence of lymph vascular emboli. When considering the size of the tumors, only stage IA myoinvasive cancers of larger than 4 cm in diameter were significantly associated with nodal disease. In addition, a statistically significant relationship was found between the number of excised lymph nodes and the possibility to detect nodal disease. CONCLUSIONS: Full surgical staging carries a substantial risk of operative complications, and, indeed, it can be avoided in most cases of grade 1 endometrial carcinomas. Nevertheless, even in the low-risk group of patients, there are clinicopathological parameters that should alert the clinician for the possibility of a more disseminated disease.

Dehydroepiandrosterone administration before IVF in poor responders: a prospective cohort study.

The use of dehydroepiandrosterone (DHEA) may improve ovarian stimulation outcomes in women of advanced reproductive age and could reduce embryo aneuploidy. In this prospective study, 48 women diagnosed with poor ovarian response received DHEA supplementation for at least 12 weeks. These women were compared with a group of poor responders (n = 113) who did not receive supplementation. During the study period, patients taking day 2 FSH and oestradiol were measured monthly before and after treatment. Stimulation characteristics, stimulation outcome and clinical outcome (clinical pregnancy and live birth rates) were reported. Evaluation of anti-Müllerian hormone (AMH) was carried out before initiation of treatment and immediately before the subsequent stimulation. Supplementation with DHEA for at least 12 weeks resulted in a modest, but statistically significant, increase in AMH levels and decrease in baseline FSH (P < 0.001 and P = 0.007, respectively). Administration of DHEA had no effect on any of the stimulation parameters nor was there any difference in clinical pregnancy rates and live birth rates between the two groups. Supplementation with DHEA significantly affects women with poor prognosis undergoing ovarian stimulation for IVF. Patients should be counselled about the uncertain effectiveness, potential side-effects and cost of this treatment.

Continuous versus cyclic use of oral contraceptives after surgery for symptomatic endometriosis: a prospective cohort study.

OBJECTIVE: To evaluate the efficacy of continuous oral contraceptive (OC) use versus the usual cyclic fashion in the recurrence of endometriosis-related symptoms after surgery. DESIGN: Prospective cohort trial involving patients in two tertiary care units. SETTING: Academic institution in collaboration with a private hospital. PATIENT(S): 356 patients underwent surgical treatment by laparoscopy for symptomatic endometriosis. INTERVENTION(S): After surgical treatment for endometriosis, patients offered 6-month course of cyclic OC (including a 7-day pill-free period) or continuous OC. MAIN OUTCOME MEASURE(S): Recurrence rate of endometriosis-related symptoms and endometriomas after fertility-sparing surgery. RESULT(S): Out of 356 patients, 167 were placed on the usual cyclic OC course and 85 on continuous OC for a minimum of 6 months. The continuous OC group experienced a statistically significant reduction in recurrence rates for endometrioma, dysmenorrhea, and non-menstrual pelvic pain as compared with the cyclic OC group. There was no reduction in the recurrence of dyspareunia between the two groups. CONCLUSION(S): After surgical treatment of endometriosis, the use of both cyclic and continuous OC improves pain symptoms when compared with preoperative scores. Continuous OC appears to be associated with a reduced recurrence rate for dysmenorrhea, non-menstrual pelvic pain, and endometrioma but not for dyspareunia as compared with cyclic OC.

Effect of pentoxifylline on vascular endothelial growth factor C and flk-1 expression on endometrial implants in the rat endometriosis model.

OBJECTIVE: To investigate the effects of pentoxifylline, on vascular endothelial growth factor (VEGF)-C and flk-1 expression in the rat endometriosis model. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: Academic institution. ANIMAL(S): Twenty Wistar rats with surgically induced endometriosis. INTERVENTION(S): Animals were evaluated after surgical induction of endometriosis and random allocation to a group that received pentoxifylline and a control group that received NaCl 0.9%, for 3 weeks. At the end of the treatment period the animals were killed and the implants evaluated macroscopically as well as by immunohistochemistry. MAIN OUTCOME MEASURE(S): Morphologic changes of the endometriotic implants; and evaluation of VEGF-C and flk-1 expression by a semiquantitative analysis (HSCORE) for the intensity of immunohistochemical reactivity. RESULT(S): A significant reduction was observed in the mean volume of the endometriotic implants per animal in the treatment group as compared with the control group. There was a significant reduction not only in the mean volume of implants per animal but also in the mean number of implants per animal after treatment. By immunohistochemical evaluation (HSCORE), there was a significant reduction in VEGF-C expression after treatment in all areas examined. A significant reduction of flk-1 expression was also noted in the glandular compartment after treatment but not in the epithelial surface or stroma. CONCLUSION(S): Pentoxifylline may cause suppression of endometriotic lesions by suppressing angiogenesis through VEGF-C and flk-1 expression.

Analgesia and anesthesia for assisted reproductive technologies.

BACKGROUND: Oocyte retrieval for in vitro fertilization (IVF) is one of the most common minor surgical procedures. OBJECTIVES: To give an update on anesthesia practices used currently in the United States and Europe in assisted reproductive technology, and discuss the safety or the potential risks for oocyte and embryo quality. SEARCH STRATEGY: Electronic search of MEDLINE for literature published between 1972 and 2008. SELECTION CRITERIA: Relevant studies on the types of anesthesia used for oocyte retrieval and the impact on oocyte and embryo quality. DATA COLLECTION AND ANALYSIS: Relevant studies were reviewed by the authors and the ones of significant scientific merit, based on methodology, were included. MAIN RESULTS: Types of anesthesia that may be used for transvaginal follicular aspiration and oocyte retrieval include: general anesthesia, neuraxial anesthesia, conscious sedation, injection of local anesthetic agents into the cervix or the vaginal wall, or any combination of the above. Conscious sedation is most commonly used in IVF because it is relatively safe and does not require the presence of an anesthesiologist when opioids or benzodiazepines are used. Propofol is the preferred anesthetic agent, but should be used by specially trained personnel. CONCLUSION: Conscious sedation is the most popular method of anesthesia used in IVF. Presently, a combination of propofol, fentanyl, and midazolam is used frequently. It is easy to administer in cooperative and motivated patients and is safe in healthy individuals; it has a relatively low risk for adverse effects on oocyte and embryo quality and pregnancy rates.

Ectopic intrathoracic thyroid: case report.

We present a patient with ectopic intrathoracic thyroid that was removed through a right lateral thoracotomy. Ectopic intrathoracic thyroid is a rare presentation of thyroid disease and comprises about 1% of all mediastinal tumors. Its removal usually necessitates thoracotomy or sternotomy. The relevant literature is briefly reviewed.