Publications by authors named "Ali Ayhan"

173 Publications

Comparison of two intraoperative examination methods for the diagnosis of sentinel lymph node metastasis in clinically early stage endometrial cancer: A Turkish Gynecologic Oncology Group Study (TRSGO-SLN-003).

Eur J Obstet Gynecol Reprod Biol 2021 Apr 20;261:72-77. Epub 2021 Apr 20.

Koç University School of Medicine, Department of Gynecology and Obstetrics, İstanbul, Turkey.

Objective: This study evaluated diagnostic accuracy of intraoperative sentinel lymph node (SLN) frozen section examination and scrape cytology as a possible solution for management of SLN positive patients.

Study Design: Clinically early-stage endometrial cancer patients who underwent SLN algorithm and intraoperative SLN examination were analyzed. Findings were compared with final pathology results and diagnostic accuracy of frozen section and scrape cytology were evaluated.

Results: Of the 208 eligible patients, 100 patients (48 %) had frozen section examination and 108 (52 %) had scrape cytology of the SLN. Intraoperative examination and final pathology were negative for metastasis in 187/208 (90 %) cases. The rest 21 cases had metastatic SLNs according to final pathology. 12 of 21 (57 %) metastases were classified as macrometastasis. Intraoperative examination of SLNs correctly identified 13 cases (true positive) and missed 8 cases (false negative). Five of 8 false negative cases had micrometastasis or isolated tumor cells. Considering identification of macrometastasis, sensitivity and negative predictive value were 85.71 % and 98.94 %, respectively, for the frozen section and 60.00 % and 98.15 %, respectively, for the scrape cytology.

Conclusion: Frozen section examination of SLN has higher sensitivity in detecting macrometastasis compared to scrape cytology and it could help the surgeon in decision for further lymphadenectomy intraoperatively.
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http://dx.doi.org/10.1016/j.ejogrb.2021.04.009DOI Listing
April 2021

Feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer during COVID-19 pandemic.

Int J Gynecol Cancer 2021 Apr 15. Epub 2021 Apr 15.

Department of Gynecology and Obstetrics Division of Gynecologic Oncology, Koç University, Istanbul, Turkey.

Objective: This study aims to evaluate the effect of the COVID-19 pandemic and related restrictions on patients who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer.

Methods: We retrospectively evaluated ovarian cancer patients who underwent HIPEC following complete cytoreductive surgery performed during the outbreak of the COVID-19 pandemic in three different centers specializing in gynecological oncology. All patients who underwent cytoreduction plus HIPEC for a primary, interval, and recurrent surgery were evaluated. Primary outcomes was postoperative 30-day morbidity and mortality. The secondary outcome was infection of patient and/or related staff with COVID-19 during the perioperative or early postoperative period.

Results: We performed a total of 35 HIPEC procedures during the pandemic: 15 (42.9%) patients underwent primary/interval surgery, while 20 (57.1%) patients had recurrent disease. Grade 3-4 complications occurred in one patient (2.9%) (chronic renal failure), while mortality did not occur in any patient. Neither the patients nor related staff were infected with the coronavirus during the perioperative or early postoperative period. One patient, who was diagnosed with COVID-19 pneumonia on postoperative day 80 died from the infection. Another patient died on postoperative day 85 due to progressive ovarian cancer, a disorder in vital functions, and organ failure.

Conclusion: HIPEC during the COVID-19 pandemic seems a safe and feasible procedure, with acceptable morbidity and mortality rates. Careful selection of patients is important and precautions should be taken before the procedure.
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http://dx.doi.org/10.1136/ijgc-2021-002511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054827PMC
April 2021

Prognostic value of the number of the metastatic lymph nodes in locally early-stage cervical cancer: squamous cell carcinoma versus non-squamous cell carcinoma.

Arch Gynecol Obstet 2021 Mar 27. Epub 2021 Mar 27.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey.

Purpose: To clarify the prognostic value of the number of metastatic lymph nodes (mLNs) in squamous and non-squamous histologies among women with node-positive cervical cancer.

Methods: One hundred ninety-one node-positive cervical cancer patients who had undergone radical hysterectomy plus systematic pelvic and para-aortic lymphadenectomy followed by concurrent radiochemotherapy were retrospectively reviewed. The prognostic value of the number of mLNs was investigated in squamous cell carcinoma (SCC) v (n = 148) and non-SCC (n = 43) histologies separately with univariate log-rank test and multivariate Cox regression analyses.

Results: In SCC cohort, mLNs > 2 was significantly associated with decreased 5-year disease-free survival (DFS) [hazard ratio (HR) = 2.06; 95% confidence interval (CI) 1.03-4.09; p = 0.03) and overall survival (OS) (HR = 2.35, 95% CI 1.11-4.99; p = 0.02). However mLNs > 2 had no significant impact on 5-year DFS and 5-year OS rates in non-SCC cohort (p = 0.94 and p = 0.94, respectively). We stratified the entire study population as SCC with mLNs ≤ 2, SCC with mLNs > 2, and non-SCC groups. Thereafter, we compared survival outcomes. The non-SCC group had worse 5-year OS (46.8% vs. 85.3%, respectively; p < 0.001) and 5-year DFS rates (31.6% vs. 82.2%, respectively; p < 0.001) when compared to those of the SCC group with mLNs ≤ 2. However, the non-SCC group and the SCC group with mLNs > 2 had similar 5-year OS (46.8% vs. 65.5%, respectively; p = 0.16) and 5-year DFS rates (31.6% vs. 57.5%, respectively; p = 0.06).

Conclusion: Node-positive cervical cancer patients who have non-SCC histology as well as those who have SCC histology with mLNs > 2 seem to have worse survival outcomes when compared to women who have SCC histology with mLNs ≤ 2.
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http://dx.doi.org/10.1007/s00404-021-06030-wDOI Listing
March 2021

Prognostic factors and survival outcomes of women with uterine leiomyosarcoma: A Turkish Uterine Sarcoma Group Study-003.

Curr Probl Cancer 2021 Feb 9:100712. Epub 2021 Feb 9.

Department of Gynecologic Oncology, Ankara State Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey.

To assess the clinicopathological features, prognostic factors, and survival rates associated with uterine leiomyosarcoma (uLMS). Databases from 15 participating gynecological oncology centers in Turkey were searched retrospectively for women who had been treated for stage I-IV uLMS between 1996 and 2018. Of 302 consecutive women with uLMS, there were 234 patients with Federation of Gynecology and Obstetrics (FIGO) stage I disease and 68 with FIGO stage II-IV disease. All patients underwent total hysterectomy. Lymphadenectomy was performed in 161 (54.5%) cases. A total of 195 patients received adjuvant treatment. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 42% and 54%, respectively. Presence of lymphovascular space invasion (LVSI), higher degree of nuclear atypia, and absence of lymphadenectomy were negatively correlated with DFS, while LVSI, mitotic count, higher degree of nuclear atypia, FIGO stage II-IV disease, and suboptimal surgery significantly decreased OS. LVSI and higher degree of nuclear atypia appear to be prognostic indicators for uLMS. Lymphadenectomy seems to have a significant effect on DFS but not on OS.
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http://dx.doi.org/10.1016/j.currproblcancer.2021.100712DOI Listing
February 2021

Impact of cytoreductive surgery on survival of patients with low-grade serous ovarian carcinoma: A multicentric study of Turkish Society of Gynecologic Oncology (TRSGO-OvCa-001).

J Surg Oncol 2021 Mar 3. Epub 2021 Mar 3.

Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, School of Medicine, Ankara Baskent University, Ankara, Turkey.

Background And Objectives: The aim of this study was to analyze the factors affecting recurrence-free (RFS) and overall survival (OS) rates of women diagnosed with low-grade serous ovarian cancer (LGSOC).

Methods: Databases from 13 participating centers in Turkey were searched retrospectively for women who had been treated for stage I-IV LGSOC between 1997 and 2018.

Results: Overall 191 eligible women were included. The median age at diagnosis was 49 years (range, 21-84 years). One hundred seventy-five (92%) patients underwent primary cytoreductive surgery. Complete and optimal cytoreduction was achieved in 148 (77.5%) and 33 (17.3%) patients, respectively. The median follow-up period was 44 months (range, 2-208 months). Multivariate analysis showed the presence of endometriosis (p = .012), lymphovascular space invasion (LVSI) (p = .022), any residual disease (p = .023), and the International Federation of Gynecology and Obstetrics (FIGO) stage II-IV disease (p = .045) were negatively correlated with RFS while the only presence of residual disease (p = .002) and FIGO stage II-IV disease (p = .003) significantly decreased OS.

Conclusions: The maximal surgical effort is warranted for complete cytoreduction as achieving no residual disease is the single most important variable affecting the survival of patients with LGSOC. The prognostic role of LVSI and endometriosis should be evaluated by further studies as both of these parameters significantly affected RFS.
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http://dx.doi.org/10.1002/jso.26450DOI Listing
March 2021

Factors affecting parametrial involvement in cervical cancer patients with tumor size ≤4 cm and selection of low-risk patient group

J Turk Ger Gynecol Assoc 2021 02 28;22(1):37-41. Epub 2021 Jan 28.

Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Ankara, Turkey

Objective: The primary aim of this study was to evaluate the factors affecting parametrial involvement in cervical cancer patients with tumor size ≤4 cm and selection of the low-risk patient group based on long-term oncologic outcomes.

Material And Methods: Cervical cancer patients operated in the gynecologic oncology division between 2007 and 2013 were retrospectively evaluated. One-hundred and sixty-eight patients with tumor size ≤4 cm were identified. Of these, 159 (86.8%) underwent radical hysterectomy plus pelvic-para-aortic lymphadenectomy and nine (13.2%) underwent fertility-sparing surgery [radical trachelectomy (n=7); large conization (n=2)]. Factors affecting parametrial invasion, including lymphovascular space invasion (LVSI), deep stromal invasion (DSI), lymph node metastases, and tumor size, were evaluated. Statistical analyses were performed using SPSS 23.0 (IBM Corp., Armonk, NY, USA).

Results: Median age was 49.5 years and median tumor size was 2.5 cm (0.45-4 cm). In both univariate and multivariate analyses, the risk of parametrial involvement was increased with LVSI with a hazard ratio (HR) of 3.45 [95% confidence interval (CI): 1.1-10.8] and DSI with a HR of 4.1 (95% CI: 1.18-14.8), while tumor size of ≤2 cm was only significant in univariate analyses. Furthermore, 26 early-stage patients were identified with low-risk factors and they had no parametrial involvement, lymph node metastases, recurrence, or death from disease over 77 months.

Conclusion: Parametrial involvement in low-risk cervical cancer is very rare and less radical procedures may be safe in these patients.
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http://dx.doi.org/10.4274/jtgga.galenos.2020.2020.0153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944230PMC
February 2021

Is the extent of lymphadenectomy a prognostic factor in International Federation of Gynecology and Obstetrics stage II endometrioid endometrial cancer?

J Obstet Gynaecol Res 2021 Mar 10;47(3):1134-1144. Epub 2021 Jan 10.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey.

Aim: This study aimed to evaluate the prognostic significance of adequate lymph node dissection (LND) (≥10 pelvic lymph nodes (LNs) and ≥ 5 paraaortic LNs removed) in patients with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrioid endometrial cancer (EEC).

Methods: A multicenter department database review was performed to identify patients who had been operated and diagnosed with stage II EEC at seven centers in Turkey retrospectively. Demographic, clinicopathological, and survival data were collected and analyzed.

Results: We identified 284 women with stage II EEC. There were 170 (59.9%) patients in the adequate lymph node dissection (LND) group and 114 (40.1%) in the inadequate LND group. The 5-year overall survival (OS) rate of the inadequate LND group was significantly lower than that of the adequate LND group (84.1% vs. 89.1%, respectively; p = 0.028). In multivariate analysis, presence of lymphovascular space invasion (LVSI) (hazard ratio [HR]: 2.39, 95% confidence interval [CI]: 1.23-4.63; p = 0.009), age ≥ 60 (HR: 3.30, 95% CI: 1.65-6.57; p = 0.001], and absence of adjuvant therapy (HR: 2.74, 95% CI: 1.40-5.35; p = 0.003) remained as independent risk factors for decreased 5-year disease-free survival (DFS). Inadequate LND (HR: 2.34, 95% CI: 1.18-4.63; p < 0.001), age ≥ 60 (HR: 2.67, 95% CI: 1.25-5.72; p = 0.011), and absence of adjuvant therapy (HR: 4.95, 95% CI: 2.28-10.73; p < 0.001) were independent prognostic factors for decreased 5-year OS in multivariate analysis.

Conclusion: Adequate LND and adjuvant therapy were significant for the improvement of outcomes in FIGO stage II EEC patients. Furthermore, LVSI was associated with worse 5-year DFS rate in stage II EEC.
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http://dx.doi.org/10.1111/jog.14648DOI Listing
March 2021

High-grade endometrial stromal sarcoma versus undifferentiated uterine sarcoma: a Turkish uterine sarcoma group study-001.

Arch Gynecol Obstet 2021 Jan 3. Epub 2021 Jan 3.

Department of Gynecologic Oncology, Saglik Bilimleri University Ankara City Hospital, Ankara, Turkey.

Objective: Prognostic factors associated with high-grade endometrial stromal sarcoma (HGESS) and undifferentiated uterine sarcoma (UUS) have not been distinctly determined due to the repetitive changes in the World Health Organization (WHO) classification. We aimed to compare clinicopathologic features and outcomes of patients with HGESS with those of patients with UUS.

Methods: A multi-institutional, retrospective, cohort study was conducted including 71 patients, who underwent surgery at 13 centers from 2008 to 2017. An experienced gynecopathologist from each institution re-evaluated the slides of their own cases according to the WHO classification. Factors associated with refractory/progressive disease, recurrence or death were examined using logistic regression analyses. Kaplan-Meier method and log-rank test were used for survival comparisons.

Results: The median disease-free survival (DFS) for HGESS and UUS was 12 months and 6 months, respectively. While the median overall survival was not reached in HGESS group, it was 22 months in the UUS group. Kaplan-Meier analyses revealed that patients with UUS had a significantly poorer DFS than those with HGESS (p = 0.016), although OS did not differ between the groups (p = 0.135). Lymphovascular-space involvement (LVSI) was the sole significant factor associated with progression, recurrence or death for HGESS (Hazard ratio: 9.353, 95% confidence interval: 2.539-34.457, p = 0.001), whereas no significant independent factor was found for UUS.

Conclusions: UUS has a more aggressive behavior than HGESS. While no significant predictor of prognosis was found for UUS, LVSI is the sole independent prognostic factor for HGESS, with patients 9.3 times more likely to experience refractory/progressive disease, recurrence or death.
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http://dx.doi.org/10.1007/s00404-020-05915-6DOI Listing
January 2021

Low-grade endometrial stromal sarcoma: A Turkish uterine sarcoma group study analyzing prognostic factors and disease outcomes.

Gynecol Oncol 2021 Mar 27;160(3):674-680. Epub 2020 Dec 27.

Department of Gynecologic Oncology, Saglik Bilimleri University Ankara City Hospital, Ankara, Turkey.

Objective: To investigate factors associated with refractory disease, recurrence, or death as well as disease-free survival (DFS) and overall survival (OS) in low-grade endometrial sarcoma (LGESS).

Methods: A multi-institutional, retrospective study was conducted in a total of 124 patients, who received a curative-intent surgery. The exclusion criteria were as follows: i) history of any other invasive disease; ii) neoadjuvant therapy; iii) fertility sparing surgery; iv) a different diagnosis after review of the slides.

Results: All patients underwent hysterectomy, 96% had bilateral salpingo-oophorectomy, and 65% had lymphadenectomy. Twelve (14.8%) of 81 patients undergoing lymphadenectomy had lymph node (LN) metastasis. Of those, 8 (9.8%) had pelvic LN metastasis whereas 4 (5.6%) had isolated paraaortic LN metastasis. Six of 8 (75%) patients with positive pelvic LNs had concurrent paraaortic LN metastasis. Among 124 patients, 3 patients (2.4%) had refractory disease following primary therapy. During a median follow-up of 45.5 months, 27 (22.3%) of 121 patients who achieved complete remission after primary therapy developed recurrence, and 10 patients (8.1%) died of disease. The 3-year DFS and OS were 76.9% and 93.8%, respectively. Stage was the sole independent prognostic factor in the whole cohort. When analyzing factors within subgroups of stage I and stage ≥II, there was no significant prognostic factor for stage I; however, lymphadenectomy and adjuvant chemotherapy were significantly associated with disease outcomes for stage ≥II. While lymphadenectomy was related with improved DFS, chemotherapy was associated with poor DFS and OS.

Conclusion: The risk of LN metastasis at pelvic as well as paraaortic lymphatic basins is not negligible to omit lymphadenectomy in stage ≥II LGESS. Moreover, lymphadenectomy provides significant DFS advantage in patients with extrauterine disease.
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http://dx.doi.org/10.1016/j.ygyno.2020.12.017DOI Listing
March 2021

Can risk groups accurately predict non-sentinel lymph node metastasis in sentinel lymph node-positive endometrial cancer patients? A Turkish Gynecologic Oncology Group Study (TRSGO-SLN-004).

J Surg Oncol 2021 Feb 1;123(2):638-645. Epub 2020 Dec 1.

Department of Gynecology and Obstetrics, Koç University School of Medicine, İstanbul, Turkey.

Background And Objectives: The purpose of this study was to find out the risk factors associated with non-sentinel lymph node metastasis and determine the incidence of non-sentinel lymph node metastasis according to risk groups in sentinel lymph node (SLN)-positive endometrial cancer patients.

Methods: Patients who underwent at least bilateral pelvic lymphadenectomy after SLN mapping were retrospectively analyzed. Patients were categorized into low, intermediate, high-intermediate, and high-risk groups defined by ESMO-ESGO-ESTRO.

Results: Out of 395 eligible patients, 42 patients had SLN metastasis and 16 (38.1%) of them also had non-SLN metastasis. Size of SLN metastasis was the only factor associated with non-SLN metastasis (p = .012) as 13/22 patients with macrometastasis, 2/10 with micrometastasis and 1/10 with isolated tumor cells (ITCs) had non-SLN metastasis. Although all 4 metastases (1.8%) among the low-risk group were limited to SLNs, the non-SLN involvement rate in the high-risk group was 42.9% and all of these were seen in patients with macrometastatic SLNs.

Conclusions: Non-SLN metastasis was more frequent in higher-risk groups and the risk of non-SLN metastasis increased with the size of SLN metastasis. Proceeding to complete lymphadenectomy when SLN is metastatic should further be studied as the effect of leaving metastatic non-SLNs in-situ is not known.
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http://dx.doi.org/10.1002/jso.26310DOI Listing
February 2021

Is the Oncological Outcome of Early Stage Uterine Carcinosarcoma Different from That of Grade 3 Endometrioid Adenocarcinoma?

Oncol Res Treat 2021 27;44(1-2):43-51. Epub 2020 Nov 27.

Department of Obstetrics and Gynecology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany.

Aim: The clinicopathologic characteristics, recurrence patterns, and survival of patients with grade 3 endometrial cancer (G3-EAC) and uterine carcinosarcoma (UCS) were compared.

Materials And Methods: The medical records of patients treated for G3-EAC and UCS between January 1996 and December 2016 at 11 gynecologic oncology centers in Turkey and Germany were analyzed.

Results: Of all patients included in the study, 161 (45.1%) were diagnosed with UCS and 196 (54.9%) with G3-EAC at FIGO stage I-II (early stage) disease. The recurrence rate was higher in patients with UCS than in those with G3-EAC (17.4 vs. 9.2%, p = 0.02). The 5-year disease-free survival (DFS; 75.2 and 80.8%, respectively; p = 0.03) and overall survival (OS; 79.4 and 83.4%, respectively; p = 0.04) rates were significantly lower in the UCS group compared to the G3-EAC group. UCS histology was an independent prognostic factor for decreased 5-year DFS (HR 1.8, 95% CI 1.2-3.2; p = 0.034) and OS (HR 2.7, 95% CI 1.3-6.9; p = 0.041) rates.

Conclusions: The recurrence rate was higher in UCS patients than in G3-EAC patients, regardless of disease stage. DFS and OS were of shorter duration in UCS than in G3-EAC patients. Adequate systematic lymphadenectomy and omentectomy were an independent prognostic factor for increased 5-year DFS and OS rates.
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http://dx.doi.org/10.1159/000511288DOI Listing
November 2020

Perioperative SARS-CoV-2 infection among women undergoing major gynecologic cancer surgery in the COVID-19 era: A nationwide, cohort study from Turkey.

Gynecol Oncol 2021 02 17;160(2):499-505. Epub 2020 Nov 17.

Department of Gynecologic Oncology, Ankara City Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey.

Objective: The objective of this study was to determine the rate of perioperative SARS-CoV-2 infection among gynecologic cancer patients undergoing major surgery.

Methods: The database of the Turkish Ministry of Health was searched in order to identify all consecutive gynecologic cancer patients undergoing major surgery between March 11, 2020 and April 30, 2020 for this retrospective, nationwide, cohort study. The inclusion criteria were strictly founded on a final histopathological diagnosis of a malignant gynecologic tumor. COVID-19 cases were diagnosed by reverse transcriptase- polymerase chain reaction testing for SARS-CoV-2. The rate of perioperative SARS-CoV-2 infection and the 30-day mortality rate of COVID-19 patients were investigated.

Results: During the study period, 688 women with gynecologic cancer undergoing major surgery were identified nationwide. The median age of the patients was 59 years. Most of the surgeries were open (634/688, 92.2%). There were 410 (59.6%) women with endometrial cancer, 195 (28.3%) with ovarian cancer, 66 (9.6%) with cervical cancer, 14 (2.0%) with vulvar cancer and 3 (0.4%) with uterine sarcoma. The rate of SARS-CoV-2 infections confirmed within 7 days before or 30 days after surgery was 46/688 (6.7%). All but one woman was diagnosed postoperatively (45/46, 97.8%). The rates of intensive care unit admission and invasive mechanical ventilation were 4/46 (8.7%) and 2/46 (4.3%), respectively. The 30-day mortality rate was 0%.

Conclusion: In the COVID-19 era, gynecologic cancer surgery may be performed with an acceptable rate of perioperative SARS-CoV-2 infection if the staff and the patients strictly adhere to the established infection control measures.
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http://dx.doi.org/10.1016/j.ygyno.2020.11.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670981PMC
February 2021

Perspectives, fears and expectations of patients with gynaecological cancers during the COVID-19 pandemic: A Pan-European study of the European Network of Gynaecological Cancer Advocacy Groups (ENGAGe).

Cancer Med 2021 01 18;10(1):208-219. Epub 2020 Nov 18.

Department of Surgery, Institute Gustave Roussy, Villejuif, France.

Background: The impact of the COVID-19 pandemic on European gynaecological cancer patients under active treatment or follow-up has not been documented. We sought to capture the patient perceptions of the COVID-19 implications and the worldwide imposed treatment modifications.

Methods: A patient survey was conducted in 16 European countries, using a new COVID-19-related questionnaire, developed by ENGAGe and the Hospital Anxiety & Depression Scale questionnaire (HADS). The survey was promoted by national patient advocacy groups and charitable organisations.

Findings: We collected 1388 forms; 592 online and 796 hard-copy (May, 2020). We excluded 137 due to missing data. Median patients' age was 55 years (range: 18-89), 54.7% had ovarian cancer and 15.5% were preoperative. Even though 73.2% of patients named cancer as a risk factor for COVID-19, only 17.5% were more afraid of COVID-19 than their cancer condition, with advanced age (>70 years) as the only significant risk factor for that. Overall, 71% were concerned about cancer progression if their treatment/follow-up was cancelled/postponed. Most patients (64%) had their care continued as planned, but 72.3% (n = 892) said that they received no information around overall COVID-19 infection rates of patients and staff, testing or measures taken in their treating hospital. Mean HADS Anxiety and Depression Scores were 8.8 (range: 5.3-12) and 8.1 (range: 3.8-13.4), respectively. Multivariate analysis identified high HADS-depression scores, having experienced modifications of care due to the pandemic and concern about not being able to visit their doctor as independent predictors of patients' anxiety.

Interpretation: Gynaecological cancer patients expressed significant anxiety about progression of their disease due to modifications of care related to the COVID-19 pandemic and wished to pursue their treatment as planned despite the associated risks. Healthcare professionals should take this into consideration when making decisions that impact patients care in times of crisis and to develop initiatives to improve patients' communication and education.
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http://dx.doi.org/10.1002/cam4.3605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753798PMC
January 2021

Nulliparity and postmenopausal status are independent factors of malignancy potential of endometrial intraepithelial neoplasia in polyps.

Int J Gynaecol Obstet 2021 Mar 15;152(3):433-438. Epub 2020 Dec 15.

Department of Obstetrics and Gynecology, Baskent University Faculty of Medicine, Ankara, Turkey.

Objective: To estimate the risk of concurrent endometrial cancer in endometrium when endometrial intraepithelial neoplasia (EIN) is found within an endometrial polyp and to identify the possible predictive factors for concurrent endometrial cancer.

Methods: Histopathologic data of women who underwent hysteroscopy for resection of endometrial polyps at Ankara Baskent University Hospital, between 2011 and 2019 were screened. Patients whose polypectomy report was EIN in a polyp, and who had a final report of the hysterectomy specimen were included. Patients were divided into two groups according to the presence of concurrent cancer in the hysterectomy material: group 1, concurrent cancer present and group 2, concurrent cancer absent. Statistical analyses were performed using SPSS.

Results: A total of 4125 women underwent hysteroscopy for the resection of endometrial polyps. Of those women, 161 (3.9%) were diagnosed as having EIN and 115 met the criteria. The rate of concurrent endometrial cancer was 28.6% (33/115). According to multivariate analysis, nulliparity (odds ratio [OR] 0.38; 95% confidence interval [CI] 1.04-3.67; p = 0.036) and postmenopausal status (OR 0.64; 95% CI 0.42-0.98; p = 0.042) were found to be independent factors significantly associated with concurrent endometrial cancer.

Conclusion: The incidence of concurrent cancer is higher in postmenopausal or nulliparous women when EIN is detected in a polyp.
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http://dx.doi.org/10.1002/ijgo.13448DOI Listing
March 2021

Prognostic factors associated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in recurrent ovarian cancer.

Int J Gynaecol Obstet 2021 Feb 28;152(2):202-207. Epub 2020 Oct 28.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Baskent University School of Medicine, Ankara, Turkey.

Objective: To identify factors affecting survival for women undergoing cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods: A retrospective study at Baskent University School of Medicine, Ankara, Turkey. Data were evaluated for 71 women with recurrent ovarian cancer who underwent cytoreductive surgery with R0 resection plus HIPEC between 2016 and 2019. Potential factors affecting survival (platinum sensitivity, bevacizumab administration before HIPEC, albumin and CA125 levels, presence of ascites, age, number of chemotherapy lines, and time interval between last chemotherapy and HIPEC) were evaluated. Complications of HIPEC were documented.

Results: The median age was 58 years, and the median follow-up was 12 months. In univariate analyses, platinum sensitivity, albumin level, and time since last chemotherapy cycle affected overall survival. In multivariate Cox regression analysis, use of bevacizumab before HIPEC (hazard ratio [HR], 6.7; 95% confidence interval [CI], 1.39-32.3; P=0.018) and presence of ascites (HR, 5.3; 95% CI, 1.65-17.5; P=0.005) were independent negative prognostic factors. Seven (8.9%) women experienced grade III-IV complications.

Conclusion: In recurrent ovarian cancer, HIPEC is a promising treatment with mild-to-moderate toxicity. However, the presence of ascites and progression under bevacizumab treatment before HIPEC seem to be negative prognostic factors; these findings will be important for patient selection.
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http://dx.doi.org/10.1002/ijgo.13410DOI Listing
February 2021

The Effects of Transobturator Tape Surgery on Sexual Functions in Women With Stress Urinary Incontinence.

Sex Med 2020 Dec 3;8(4):777-782. Epub 2020 Sep 3.

Department of Obstetrics and Gynecology, Faculty of Medicine, Başkent University, Ankara, Turkey.

Introduction: Stress urinary incontinence (SUI) can adversely affect the patient's sexual function.

Aim: To evaluate the sexual functions in women who underwent transobturator tape (TOT) surgery because of stress urinary incontinence and factors affecting the treatment results.

Methods: The study was conducted in 2 tertiary level clinics between 2013 and 2019 and included sexually active patients with a diagnosis of SUI who underwent TOT operation. The preoperative and postoperative (6 months after surgery) Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores of the patients were evaluated. The patients were evaluated according to the score changes of an increased score (benefited) and the same or lower score (did not benefit). The PISQ-12 questionnaire has 3 subdomains of behavioral-emotive (Q: 1-4), physical (Q: 5-9), and partner-related (Q: 10-12). Each question is scored from 0 to 4, giving a total ranging from 0 to 48. A higher PISQ-12 score indicates better sexual function.

Main Outcome Measure: PISQ-12.

Results: The study included 117 patients with a median age of 52 years (range, 32-67 years), and 51.3% of the patients were postmenopausal. When the preoperative and postoperative PISQ-12 scores were evaluated in the whole group, there was a statistically significant improvement (from 24.66 to 26.52, P = .001). In the analysis of domains, there was a statistically significant improvement in physical score (from 11.68 to 13.53, P < .001), whereas behavioral-emotive and partner-related scores did not significantly change. In the multivariate analysis of menopausal status, parity and presence of diabetes mellitus were all independently and significantly associated with poor PISQ-12 outcome (OR: 2.60, 95% CI: 1.41-4.81, P = .002; OR: 1.59, 95% CI: 1.03-2.47, P = .034; and OR: 2.42, 95% CI: 1.28-4.58, P = .007, respectively).

Conclusion: Both physical and psychological statuses should be taken into consideration when planning treatment in patients with urinary incontinence, and it should be noted that postsurgical sexual function status may not be positively affected in postmenopausal, multiparous, and diabetic patients. Kizilkan Y, Tohma YA, Senel S, et al. The Effects of Transobturator Tape Surgery on Sexual Functions in Women With Stress Urinary Incontinence. Sex Med 2020;8:777-782.
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http://dx.doi.org/10.1016/j.esxm.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691869PMC
December 2020

Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: an international survey of peri-operative practice.

Int J Gynecol Cancer 2020 10 4;30(10):1471-1478. Epub 2020 Aug 4.

Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada.

Introduction: Enhanced Recovery After Surgery (ERAS) programs have been shown to improve clinical outcomes in gynecologic oncology, with the majority of published reports originating from a small number of specialized centers. It is unclear to what degree ERAS is implemented in hospitals globally. This international survey investigated the status of ERAS protocol implementation in open gynecologic oncology surgery to provide a worldwide perspective on peri-operative practice patterns.

Methods: Requests to participate in an online survey of ERAS practices were distributed via social media (WhatsApp, Twitter, and Social Link). The survey was active between January 15 and March 15, 2020. Additionally, four national gynecologic oncology societies agreed to distribute the study among their members. Respondents were requested to answer a 17-item questionnaire about their ERAS practice preferences in the pre-, intra-, and post-operative periods.

Results: Data from 454 respondents representing 62 countries were analyzed. Overall, 37% reported that ERAS was implemented at their institution. The regional distribution was: Europe 38%, Americas 33%, Asia 19%, and Africa 10%. ERAS gynecologic oncology guidelines were well adhered to (>80%) in the domains of deep vein thrombosis prophylaxis, early removal of urinary catheter after surgery, and early introduction of ambulation. Areas with poor adherence to the guidelines included the use of bowel preparation, adoption of modern fasting guidelines, carbohydrate loading, use of nasogastric tubes and peritoneal drains, intra-operative temperature monitoring, and early feeding.

Conclusion: This international survey of ERAS in open gynecologic oncology surgery shows that, while some practices are consistent with guideline recommendations, many practices contradict the established evidence. Efforts are required to decrease the variation in peri-operative care that exists in order to improve clinical outcomes for patients with gynecologic cancer globally.
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http://dx.doi.org/10.1136/ijgc-2020-001683DOI Listing
October 2020

Prognostic impact of p16 and p53 gene expressions in stage 1a epithelial ovarian cancer.

Obstet Gynecol Sci 2020 Jul 19;63(4):464-469. Epub 2020 Jun 19.

Department of Obstetrics and Gynecology, School of Medicine, Başkent University, Ankara, Turkey.

Objective: Epithelial ovarian cancer (EOC) is rarely detected at stage 1a. Most of the patients have a good prognosis and there are limited factors that affect their survival. In the present study, we evaluated the p16 and p53 gene expressions of stage 1a EOC patients. Prognostic effects of these gene expressions, as well as those of other factors on short term survival were analyzed.

Methods: Our study included 29 patients. The specimens of the ovary with cancer were stained for p16 and p53. Gene expressions and other prognostic factors were evaluated.

Results: The median age of the patients was 51 years (27-84). The mean numbers of dissected pelvic and paraaortic lymph nodes were 27 and 12, respectively. The mean follow-up time was 33.7±18.9 months. During this period, recurrence occurred in two patients. One of the patients had grade 2 mucinous carcinoma and died of the disease at month 12 after the recurrence occurred at month 7. The second patient had clear cell carcinoma and recurrence occurred at month 34. p16 and p53 gene expressions or other factors were not associated with overall survival (OS) or disease-free survival in the short term. The lower p16 positivity rate in the non-clear cell group was found to be statistically significant (P=0.003). Both p53 and p16 positivity rates were higher in the high-grade carcinoma.

Conclusion: The levels of none of the common prognostic factors, including those of p16 and p53 gene expression, were associated with the progression-free survival or OS of stage 1a in the short term. Appropriate surgical staging and non-omission of subclinical metastases seem to be of central importance.
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http://dx.doi.org/10.5468/ogs.19204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393742PMC
July 2020

Combination of sentinel lymph node mapping and uterine frozen section examination to reduce side-specific lymphadenectomy rate in endometrial cancer: a Turkish Gynecologic Oncology Group study (TRSGO-SLN-002).

Int J Gynecol Cancer 2020 07 30;30(7):1005-1011. Epub 2020 May 30.

Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey.

Objective: This study aimed to find out whether side-specific pelvic lymphadenectomy can be omitted without compromising diagnostic efficacy according to "reflex frozen section" analysis of the uterus in case of sentinel lymph node (SLN) mapping failure.

Methods: Patients who underwent surgery for endometrial cancer with an SLN algorithm were stratified as low-risk or high-risk according to the uterine features on the final pathology reports. Two models for low-risk patients were defined to omit side-specific pelvic lymphadenectomy: strategy A included patients with endometrioid histology, grade 1-2, and <50% myometrial invasion irrespective of the tumor diameter; strategy B included all factors of strategy A with the addition of tumor diameter ≤2 cm. Theoretical side-specific pelvic lymphadenectomy rates were calculated for the two strategies, assuming side-specific pelvic lymphadenectomy was omitted if low-risk features were present on reflex uterine frozen examination, and compared with the standard National Comprehensive Cancer Network (NCCN) SLN algorithm.

Results: 372 endometrial cancer patients were analyzed. 230 patients (61.8%) had endometrioid grade 1 or 2 tumors with <50% myometrial invasion (strategy A), and in 123 (53.4%) of these patients the tumor diameter was ≤2 cm (strategy B); 8 (3.5%) of the 230 cases had lymphatic metastasis. None of them were detected by side-specific pelvic lymphadenectomy and metastases were limited to SLNs in 7 patients. At least one pelvic side was not mapped in 107 (28.8%) cases in the entire cohort, and all of these cases would require a side-specific pelvic lymphadenectomy based on the NCCN SLN algorithm. This rate could have been significantly decreased to 11.8% and 19.4% by applying reflex frozen section examination of the uterus using strategy A and strategy B, respectively.

Conclusion: Reflex frozen section examination of the uterus can be a feasible option to decide whether side-specific pelvic lymphadenectomy is necessary for all the patients who failed to map with an SLN algorithm. If low-risk factors are found on frozen section examination, side-specific pelvic lymphadenectomy can be omitted without compromising diagnostic efficacy for lymphatic spread.
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http://dx.doi.org/10.1136/ijgc-2020-001353DOI Listing
July 2020

Fertility preservation in early-stage endometrial cancer and endometrial intraepithelial neoplasia: A single-center experience.

Taiwan J Obstet Gynecol 2020 May;59(3):415-419

Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey.

Objective: The purpose of this study was to define the pregnancy and oncologic outcomes after fertility-sparing treatment of atypical hyperplasia (AH)/endometrial intraepithelial neoplasia (EIN) and early-stage endometrioid endometrial cancer (EEC).

Materials And Methods: The retrospective cohort study included patients who had applied to Başkent University's Ankara Hospital between January 2007 and October 2018 with either AH/EIN (n: 27; Group A) or EEC (n: 30; Group B), and who had the desire to preserve their fertility. The medical records of all patients included in the study were reviewed retrospectively from the hospital records.

Results: There were 2 (7.4%) and 5 (16.7%) recurrences, whereby one patient from Group A and two patients from Group B underwent staging surgery. In Group A, 8 patients attempted pregnancy after their treatment and 4 of them (50%) became pregnant, while 3 of them (37.5%) had a live birth. In Group B, there were 17 patients who wanted to become pregnant following treatment of the disease; 8 of them (47%) became pregnant after treatment, 5 of them (16.6%) had a live birth, 1 experienced intrauterine exitus (at 21st gestational week, 350 g), and 2 currently have ongoing pregnancies.

Conclusion: Hysteroscopic resection of visible lesions and full endometrial curettage prior to hormonal therapy as a fertility-preserving approach for women of reproductive age with endometrial malignancies can achieve promising oncologic and obstetric responses.
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http://dx.doi.org/10.1016/j.tjog.2020.03.014DOI Listing
May 2020

Does lymph node ratio have any prognostic significance in maximally cytoreduced node-positive low-grade serous ovarian carcinoma?

Arch Gynecol Obstet 2020 07 14;302(1):183-190. Epub 2020 May 14.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey.

Purpose: To determine the prognostic impact of the lymph node ratio (LNR) in node-positive low-grade serous ovarian cancer (LGSOC).

Methods: We retrospectively reviewed women with LGSOC who had undergone maximal cytoreduction followed by standard chemotherapy in 11 centers from Turkey during a study period of 20 years. Sixty two women with node-positive LGSOC were identified. LNR was defined as the number of metastatic lymph nodes (LNs) divided by the number of total LNs removed. We grouped patients pursuant to the LNR as LNR ≤ 0.09 and LNR > 0.09. The prognostic value of LNR was investigated by employing the univariate log-rank test and multivariate Cox-regression model.

Results: With a median follow-up of 45 months, the 5-year progression-free survival (PFS) rates were 61.7% for women with LNR ≤ 0.09 and 32.0% for those with LNR > 0.09 (p = 0.046) whereas, the 5-year overall survival (OS) rates were 72.8% for LNR ≤ 0.09 and 54.7% for LNR > 0.09 (p = 0.043). On multivariate analyses, lymphovascular space invasion (LVSI) (Hazard Ratio [HR] 4.18, 95% confidence interval [CI] 1.88-9.27; p < 0.001), omental involvement (HR 3.48, 95% CI 1.36-8.84; p = 0.009) and LNR > 0.09 (HR 3.51, 95% CI 1.54-8.03; p = 0.003) were adverse prognostic factors for PFS. Additionally, LVSI (HR 6.56, 95% CI 2.33-18.41; p < 0.001), omental involvement (HR 6.34, 95% CI 1.86-21.57; p = 0.003) and LNR > 0.09 (HR 7.20, 95% CI 2.33-22.26; p = 0.001) were independent prognostic factors for decreased OS.

Conclusion: LNR > 0.09 seems to be an independent prognosticator for decreased survival outcomes in LGSOC patients who received maximal cytoreduction followed by standard adjuvant chemotherapy.
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http://dx.doi.org/10.1007/s00404-020-05580-9DOI Listing
July 2020

Multi-institutional validation of the ESMO-ESGO-ESTRO consensus conference risk grouping in Turkish endometrial cancer patients treated with comprehensive surgical staging.

J Obstet Gynaecol 2020 Apr 29:1-7. Epub 2020 Apr 29.

Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey.

In this study, 683 patients with endometrial cancer (EC) after comprehensive surgical staging were classified into four risk groups as low (LR), intermediate (IR), high-intermediate (HIR) and high-risk (HR), according to the recent consensus risk grouping. Patients with disease confined to the uterus, ≥50% myometrial invasion (MI) and/or grade 3 histology were treated with vaginal brachytherapy (VBT). Patients with stage II disease, positive/close surgical margins or extra-uterine extension were treated with external beam radiotherapy (EBRT)±VBT. The median follow-up was 56 months. The overall survival (OS) was significantly different between LR and HR groups, and there was a trend between LR and HIR groups. Relapse-free survival (RFS) was significantly different between LR and HIR, LR and HR and IR and HR groups. There was no significant difference in OS and RFS rates between the HIR and HR groups. In HR patients, the OS and RFS rates were significantly higher in stage IB - grade 3 and stage II compared to stage III and non-endometrioid histology without any difference between the two uterine-confined stages and between stage III and non-endometrioid histology. The current risk grouping does not clearly discriminate the HIR and IR groups. In patients with comprehensive surgical staging, a further risk grouping is needed to distinguish the real HR group.Impact statement The standard treatment for endometrial cancer (EC) is surgery and adjuvant radiotherapy (RT) and/or chemotherapy is recommended according to risk factors. The recent European Society for Medical Oncology (ESMO), European Society of Gynaecological Oncology (ESGO) and European Society for Radiotherapy and Oncology (ESTRO) guideline have introduced a new risk group. However, the risk grouping is still quite heterogeneous. This study demonstrated that the current risk grouping recommended by ESMO-ESGO-ESTRO does not clearly discriminate the intermediate risk (IR) and high-intermediate risk (HIR) groups. Based on the results of this study, a new risk grouping can be made to discriminate HIR and IR groups clearly in patients with comprehensive surgical staging.
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http://dx.doi.org/10.1080/01443615.2020.1737661DOI Listing
April 2020

Changes of Stress Distributions Around Pterygomaxillary Junction With Different Osteotome Angulations.

J Craniofac Surg 2020 Sep;31(6):1560-1562

Department of Oral and Maxillofacial Surgery, Istanbul Medipol University School of Dentistry, Istanbul.

The aim of this study was to investigate how the alteration of the angulation of osteotome at pterygomaxillary junction affects lateral pterygoid plate, maxillary tuberosity, palatal surface of maxilla, palatine bone and body of sphenoid bone. Following reconstruction of 3D modelling of maxilla, Osteotomes' tip was angulated 45 and 90 to sagittal plane to simulate pterygomaxillary osteotomy. Finite element analyses (FEA) was performed and Von Misses stress distributions were analyzed for two different angulations. Independent sample t test was used to compare differences between 45 and 90 angulations. Von Misses stress values on lateral pterygoid plate were higher in 45 angulation (0.71 ± 0.21 MPa) than 90 angulation (0.54 ± 0.28 MPa). This difference was statistically significant (P < 0.01). Placement of osteotome's tip with 90 angulation had higher stress value than 45 angulation on maxillary tuberosity region. However; difference wasn't significant (P = 0.44). Stress values on body of sphenoid bone were 0.45 ± 0.17MPa for the case of 90 angulation and 0.19 ± 0.09MPa for 45 angulation. Difference between these values were statistically significant (P < 0.01). Possible risk of unfavourable lateral pterygoid plate fracture and complications related with body of sphenoid bone during pterygomaxillary osteotomy was remarkably increased in case of narrow angulation (45). Keeping osteotome at right angle with sagittal plane may avoid these complications.
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http://dx.doi.org/10.1097/SCS.0000000000006397DOI Listing
September 2020

Comparison of no adjuvant treatment and radiotherapy in early-stage cervical carcinoma with intermediate risk factors.

Int J Gynaecol Obstet 2020 Jun 22;149(3):298-302. Epub 2020 Apr 22.

Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Baskent University School of Medicine, Ankara, Turkey.

Objective: To evaluate the results of receiving no adjuvant treatment (NAT) or radiotherapy after radical hysterectomy in patients with International Federation of Gynecology and Obstetrics 2018 Stage IB1-IB3 cervical cancer with intermediate risk factors.

Methods: A retrospective cohort study was conducted at Baskent University School of Medicine's Department of Gynecology and Obstetrics in Ankara, Turkey between January 1, 2008, and December 31, 2016. In total, 134 women with at least two intermediate risk factors (positive LVSI, deep stromal invasion, and tumor size ≥4 cm) were included in the study. Patients were divided into two groups: NAT and radiotherapy.

Results: There were 66 patients in the NAT group and 68 in the radiotherapy group. The median follow-up time was 61.05 months. The 5-year overall survival (OS) rates were similar in both groups (84.1% vs 82.9%, respectively; P=0.57), while the 5-year disease-free survival (DFS) rates were 80.2% and 78.2% in the NAT and radiotherapy groups, respectively (P=0.25). Most importantly, both groups had similar local recurrence rates: 8 (12.1%) in the NAT group and 9 (13.2%) in the radiotherapy group (P=0.82). Multivariant analyses showed that the only independent risk factor for recurrence was tumor size ≥4 cm with a hazard ratio of 2.4 (95% confidence interval 1.12-5.24; P=0.02).

Conclusion: Adjuvant treatment improved neither DFS nor local recurrence rates.
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http://dx.doi.org/10.1002/ijgo.13147DOI Listing
June 2020

Factors associated with surgical morbidity of primary debulking in epithelial ovarian cancer.

Obstet Gynecol Sci 2020 Jan 31;63(1):64-71. Epub 2019 Dec 31.

Department of Obstetrics and Gynecology, Baskent University School of Medicine, Ankara, Turkey.

Objective: Epithelial ovarian cancer (EOC) requires an aggressive surgical approach. The important part of literature on ovarian cancer surgery emphasize residual tumor and survival analyses. Morbidity issue keeps in background. Therefore, we aimed to report on morbidity of cytoreductive surgery for EOC in this study.

Methods: EOC patients who underwent primary debulking were evaluated. Intraoperative and postoperative complications that occurred within 30 days after the surgery and factors that affect morbidity were considered.

Results: The study involved 359 patients. Forty-six intraoperative complications occurred in 42 (11.6%) patients. Advanced stage and cancer antigen level of 125 were independently and significantly associated with operative complications (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.01-2,73; =0.044, and HR, 1.47; 95% CI, 1.05-2.06; =0.025, respectively). The need for intensive care unit admission was significantly higher in patients with intraoperative complications (28.6% vs. 8.8%, =0.001). Intraoperative and postoperative complication rates were significantly higher in extended surgery than in standard surgery (18.9%vs. 8.5%, =0.005 and 38.7% vs. 10.9%, <0.001, respectively). Intraoperative and postoperative transfusion need, hospital stay duration, and chemotherapy start day were also significantly higher in extended surgery than in standard surgery. Hundred postoperative complications occurred in 70 patients. Age, extended surgery, presence of ascites, and presence of operative complications were independently and significantly associated with postoperative complications.

Conclusion: Morbidity of extensive surgical approach should be kept in mind in ovarian cancer surgery aimed at leaving no residual tumor. Patient-based management with an appropriate preoperative evaluation may avoid morbidity of extended/extensive surgical approaches.
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http://dx.doi.org/10.5468/ogs.2020.63.1.64DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6962589PMC
January 2020

Sentinel lymph node biopsy in early stage endometrial cancer: a Turkish gynecologic oncology group study (TRSGO-SLN-001).

Int J Gynecol Cancer 2020 03 18;30(3):299-304. Epub 2019 Dec 18.

Obstetrics and Gynecology, Koc University Medical Faculty, Istanbul, Turkey.

Objective: The aim of this multicenter study was to evaluate the feasibility of sentinel lymph node (SLN) mapping in clinically uterine confined endometrial cancer.

Methods: Patients who underwent primary surgery for endometrial cancer with an SLN algorithm were reviewed. Indocyanine green or blue dye was used as a tracer. SLNs and/or suspicious lymph nodes were resected. Side specific lymphadenectomy was performed when mapping was unsuccessful. SLNs were ultrastaged on final pathology.

Results: 357 eligible patients were analyzed. Median age was 59 years. Median number of resected SLNs was 2 (range 1-12) per patient. Minimal invasive and open surgeries were performed in 264 (73.9%) and 93 (26.1%) patients, respectively. Indocyanine green was used in 231 (64.7%) and blue dye in 126 (35.3%) patients. The dyes were injected into the cervix in 355 (99.4%) patients. The overall and bilateral SLN detection rates were 91.9% and 71.4%, respectively. The mapping rates using indocyanine green or blue dye were comparable (P=0.526). There were 43 (12%) patients with lymphatic metastasis. The SLN algorithm was not able to detect 3 of 43 patients who had isolated paraaortic metastasis. After SLN biopsy, complete pelvic lymphadenectomy was performed in 286 (80.1%) patients. Sensitivity and negative predictive value were both 100% for the detection of pelvic lymph node metastases. In addition, 117 (32.8%) patients underwent completion paraaortic lymphadenectomy after SLN biopsy. In these patients, sensitivity for detecting metastases to pelvic and/or paraaortic lymph nodes was 90.3% with a negative predictive value of 96.6%. The risk of non-SLN involvement in patients with macrometastatic SLNs, micrometastatic SLNs, and isolated tumor cells in SLNs were 61.2%, 14.3% and 0%, respectively.

Conclusions: SLN biopsy had good accuracy in detecting lymphatic metastasis. However, one-third of cases with metastatic SLNs also had non-SLN involvement and this risk increased to two-thirds of cases with macrometastatic SLNs. The effect of leaving these nodes in situ on survival should be evaluated in further studies.
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http://dx.doi.org/10.1136/ijgc-2019-000847DOI Listing
March 2020

The prognostic value of lymph node ratio in stage IIIC cervical cancer patients triaged to primary treatment by radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy.

J Gynecol Oncol 2020 Jan 24;31(1):e1. Epub 2019 Jun 24.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey.

Objective: The aim of this study was to determine the prognostic value of lymph node ratio (LNR) in women with 2018 International Federation of Gynecology and Obstetrics stage IIIC cervical cancer.

Methods: In this retrospective dual-institutional study, a total of 185 node-positive cervical cancer patients who had undergone radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy were included. All of the patients received adjuvant chemoradiation after surgery. LNR was defined as the ratio of positive lymph nodes (LNs) to the total number of LNs removed. The patients were categorized into 2 groups according to LNR; LNR <0.05 and LNR ≥0.05. The prognostic value of LNR was evaluated with univariate log-rank tests and multivariate Cox regression models.

Results: A total of 138 patients (74.6%) had stage IIIC1 disease and 47 (25.4%) patients had stage IIIC2 disease. With a median follow-up period of 45.5 months (range 3-135 months), the 5-year disease-free survival (DFS) rate was 62.5% whereas the 5-year overall survival (OS) rate was 70.4% for the entire study population. The 5-year DFS rates for LNR <0.05 and LNR ≥0.05 were 78.2%, and 48.4%, respectively (p<0.001). Additionally, the 5-year OS rates for LNR <0.05 and LNR ≥0.05 were 80.6%, and 61.2%, respectively (p=0.007). On multivariate analysis, LNR ≥0.05 was associated with a worse DFS (hazard ratio [HR]=2.12; 95% confidence interval [CI]=1.15-3.90; p=0.015) and OS (HR=1.95; 95% CI=1.01-3.77; p=0.046) in women with stage IIIC cervical cancer.

Conclusions: LNR ≥0.05 seems to be an independent prognostic factor for decreased DFS and OS in stage IIIC cervical carcinoma.
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http://dx.doi.org/10.3802/jgo.2020.31.e1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918892PMC
January 2020

Oncologic outcomes in patients undergoing maximal or optimal cytoreductive surgery for Stage 3C serous ovarian, tubal or peritoneal carcinomas.

J Obstet Gynaecol 2020 May 4;40(4):551-557. Epub 2019 Sep 4.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey.

The aim of this study was to evaluate overall survival (OS) and disease-free survival (DFS) of patients with Stage 3C serous ovarian, tubal and peritoneal carcinomas. A retrospective analysis of 111 patients who underwent maximal or optimal cytoreductive surgery was performed. Patients were divided into three groups as ovarian cancer ( = 47), tubal cancer ( = 24) and peritoneal cancer ( = 40). Median follow-up was 30 months. There was no significant difference in DFS and OS among the groups. Complete cytoreduction was an independent prognostic factor for DFS in all groups (HR 2.3, 95% CI 1.14-4.93; =.020). Positive peritoneal cytology (HR 2.2, 95% CI 1.02-4.78; =.044), and retroperitoneal lymph node involvement (HR 2.3, 95% CI1.11-4.89; =.025) were independent risk factors for decreased OS, and extended cytoreduction (HR 2.7, 95% CI 1.05-6.99; =.039) were independent risk factors for increased OS. In conclusion, these malignancies should be considered a single entity during treatment.IMPACT STATEMENT Epithelial ovarian cancer is the second most common gynaecological cancer in women worldwide. There are different histological types including ovarian, tubal and peritoneal carcinomas in which malignant cells form in the tissue covering the ovary or lining the fallopian tube of peritoneum. Recent data have supported the view that these malignancies should be considered a single entity and should be treated the same way. In the present study, we evaluated overall survival and disease-free survival of patients with Stage 3C ovarian, tubal and peritoneal cancer undergoing maximal or optimal cytoreductive surgery. We found similar oncologic outcomes in all patient groups. To the best of our knowledge, this is the first study to compare oncologic outcomes of these similar and often confused malignancies in the literature. We, therefore, believe that the present study provides additional information to the body of knowledge on this topic. This study is important, as it indicates similar oncologic outcomes in patients undergoing maximal or optimal cytoreductive surgery for Stage 3C ovarian, tubal and peritoneal cancer. Based on these findings, clinicians should keep in mind that these malignancies should be considered a single clinical entity and be treated the same way. We believe that our study would pave the way for further studies regarding this subject.
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http://dx.doi.org/10.1080/01443615.2019.1634028DOI Listing
May 2020

SATEN III-Splitting Adjuvant Treatment of stage III ENdometrial cancers: an international, multicenter study.

Int J Gynecol Cancer 2019 10 2;29(8):1271-1279. Epub 2019 Sep 2.

Department of Gynecologic Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Introduction: The purposes of this study were to compare adjuvant treatment modalities and to determine prognostic factors in stage III endometrioid endometrial cancer (EC).

Methods: SATEN III was a retrospective study involving 13 centers from 10 countries. Patients who had been operated on between 1998 and 2018 and diagnosed with stage III endometrioid EC were analyzed.

Results: A total of 990 women were identified; 317 with stage IIIA, 18 with stage IIIB, and 655 with stage IIIC diseases. The median follow-up was 42 months. The 5-year disease-free survival (DFS) of patients with stage III EC by adjuvant treatment modality was 68.5% for radiotherapy (RT), 54.6% for chemotherapy (CT), and 69.4% for chemoradiation (CRT) (p=0.11). The 5-year overall survival (OS) for those patients was 75.6% for RT, 75% for CT, and 80.7% for CRT (p=0.48). For patients with stage IIIA disease treated by RT versus CT versus CRT, the 5-year OS rates were 75.6%, 75.0%, and 80.7%, respectively (p=0.48). Negative peritoneal cytology (HR: 0.45, 95% CI: 0.23 to 0.86; p=0.02) and performance of lymphadenectomy (HR: 0.33, 95% CI: 0.16 to 0.77, p=0.001) were independent predictors for improved OS for stage IIIA EC. For women with stage IIIC EC treated by RT, CT, and CRT, the 5-year OS rates were 78.9%, 67.0%, and 69.8%, respectively (p=0.08). Independent prognostic factors for better OS for stage IIIC disease were age <60 (HR: 0.50, 95%CI: 0.36 to 0.69, p<0.001), grade 1 or 2 disease (HR: 0.59, 95% CI: 0.37 to 0.94, p=0.014; and HR: 0.65, 95%CI: 0.46 to 0.91, p=0.014, respectively), absence of cervical stromal involvement (HR: 063, 95% CI: 0.46 to 0.86, p=0.004) and performance of para-aortic lymphadenectomy (HR: 0.52, 95% CI: 0.35 to 0.72, p<0.001).

Discussion: Although not statistically significant, CRT seemed to be a better adjuvant treatment option for stage IIIA endometrioid EC. Systematic lymphadenectomy seemed to improve survival outcomes in stage III endometrioid EC.
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http://dx.doi.org/10.1136/ijgc-2019-000643DOI Listing
October 2019