Publications by authors named "Tayfun Toptas"

37 Publications

Radical hysterectomy in early cervical cancer in Europe: characteristics, outcomes and evaluation of ESGO quality indicators.

Int J Gynecol Cancer 2021 Jul 28. Epub 2021 Jul 28.

Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Introduction: Comprehensive updated information on cervical cancer surgical treatment in Europe is scarce.

Objective: To evaluate baseline characteristics of women with early cervical cancer and to analyze the outcomes of the ESGO quality indicators after radical hysterectomy in the SUCCOR database.

Methods: The SUCCOR database consisted of 1272 patients who underwent radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) between January 2013 and December 2014. After exclusion criteria, the final sample included 1156 patients. This study first described the clinical, surgical, pathological, and follow-up variables of this population and then analyzed the outcomes (disease-free survival and overall survival) after radical hysterectomy. Surgical-related ESGO quality indicators were assessed and the accomplishment of the stated recommendations was verified.

Results: The mean age of the patients was 47.1 years (SD 10.8), with a mean body mass index of 25.4 kg/m (SD 4.9). A total of 423 (36.6%) patients had a previous cone biopsy. Tumor size (clinical examination) <2 cm was observed in 667 (57.7%) patients. The most frequent histology type was squamous carcinoma (794 (68.7%) patients), and positive lymph nodes were found in 143 (12.4%) patients. A total of 633 (54.8%) patients were operated by open abdominal surgery. Intra-operative complications occurred in 108 (9.3%) patients, and post-operative complications during the first month occurred in 249 (21.5%) patients, with bladder dysfunction as the most frequent event (119 (10.3%) patients). Clavien-Dindo grade III or higher complication occurred in 56 (4.8%) patients. A total of 510 (44.1%) patients received adjuvant therapy. After a median follow-up of 58 months (range 0-84), the 5-year disease-free survival was 88.3%, and the overall survival was 94.9%. In our population, 10 of the 11 surgical-related quality indicators currently recommended by ESGO were fully fulfilled 5 years before its implementation.

Conclusions: In this European cohort, the rate of adjuvant therapy after radical hysterectomy is higher than for most similar patients reported in the literature. The majority of centers were already following the European recommendations even 5 years prior to the ESGO quality indicator implementations.
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http://dx.doi.org/10.1136/ijgc-2021-002587DOI Listing
July 2021

Prophylactic subcutaneous retention sutures in the prevention of superficial wound separation of midline laparotomy.

Int J Gynecol Cancer 2021 Jul 21. Epub 2021 Jul 21.

Department of Gynecology and Obstetrics, Antalya Training and Research Hospital, Antalya, Turkey.

Objectives: This prospective study aimed to determine the effectiveness of prophylactic subcutaneous retention sutures in the prevention of superficial wound separation in women with a confirmed or suspected cancer who had gynecological surgery by midline laparotomy.

Methods: This was a non-randomized, controlled intervention study including patients who underwent cancer surgery between May 2018 and August 2019. Patients who underwent midline laparotomy with confirmed or suspected cancer were included and patients who had an early post-operative complication or who underwent surgery again before the removal of stitches were excluded. The independent variables that might predict the superficial wound site dehiscence and prolongation of the hospitalization period were analyzed using logistical regression analysis.

Results: A total of 208 patients were included in the study. Age, presence of comorbid diseases, low pre-operative hemoglobin, low pre-operative albumin, higher weight, higher body mass index (BMI), pre- and post-operative blood transfusion, and absence of retention sutures were associated with higher risk of superficial wound separation. Low pre-operative albumin, weight, and BMI were associated with prolonged length of hospital stay. In a multivariate analysis, BMI (OR: 1.12; 95% CI: 1.09 to 1.28, p<0.001) and retention sutures (OR: 0.31; 95% CI: 0.11 to 0.83, p=0.019) retained an independent association with superficial wound separation. In addition, BMI (OR: 1.11; 95% CI: 1.03 to 1.25, p=0.010) and intra-operative complications (OR: 4.10; 95% CI: 1.08 to 15.60, p=0.038) were independent predictors increasing the length of hospital stay, and use of retention sutures (OR: 0.19; 95% CI: 0.05 to 0.66, p=0.009) was an independent predictor decreasing the length of hospital stay.

Conclusions: Prophylactic subcutaneous retention sutures reduced superficial wound separation and shortened hospital stay. Prophylactic subcutaneous retention sutures may be considered in patients who undergo gynecological surgery using a midline laparotomy.
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http://dx.doi.org/10.1136/ijgc-2021-002446DOI Listing
July 2021

Obstetrician-gynecologists' practice patterns regarding HPV testing in cervical cancer screening in Turkey.

Turk J Obstet Gynecol 2021 Mar;18(1):15-22

University of Health Sciences Turkey, Antalya Training and Research Hospital, Clinic of Obstetrics and Gynecology, Antalya, Turkey.

Objective: To determine obstetrician-gynecologists' (OBGYNs) practice patterns regarding human papillomavirus (HPV) testing in cervical cancer screening. Secondly, we aimed to examine OBGYNs' adherence to guidelines in the management of women with HPV-positive test results.

Materials And Methods: The study was a cross-sectional survey conducted in Antalya and Istanbul provinces in Turkey using a self-reported questionnaire. A 12-item questionnaire form was administered to the participants in face-to-face interviews. Of the targeted participants, 343 OBGYNs completed the questionnaire.

Results: The majority of participants, (81.0%) stated that they offered/used HPV testing in cervical cancer screening. Of those, most OBGYNs (89.9%) preferred to use HPV testing concomitant with cervical cytology (co-testing) whereas only 10.1% preferred to use HPV testing alone (primary HPV testing). The most preferred screening intervals for women with HPV-negative results were 5 years (53.4%) and 3 years (19.9%), respectively. In compliance with the guidelines, the rate of participants who recommended "referral directly to colposcopy" for women who were HPV16/18-positive and cytology-negative; and "co-testing at 12 months" for women who were positive for HPV genotypes other than HPV16/18 and cytology-negative was 53.1%. Multivariate analysis revealed that the "professional working setting" was the sole independent determinant of the adherence to the guidelines. OBGYNs working in private settings had the worst adherence rate (42.4%).

Conclusion: Primary HPV testing is not yet widespread among Turkish OBGYNs. Moreover, adherence to practice guidelines in the management of HPVpositive test results is relatively low. There is a need for continuing medical education regarding screening programs and the management of women with positive screening results.
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http://dx.doi.org/10.4274/tjod.galenos.2021.36418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962162PMC
March 2021

The role of lymphadenectomy in patients with stage III&IV uterine serous carcinoma: Results of multicentric Turkish study.

J Gynecol Obstet Hum Reprod 2021 May 13;50(5):102063. Epub 2021 Jan 13.

Department of Gynecologic Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey. Electronic address:

Objective: The aim of this study was to evaluate clinicopathological features, oncological outcome and prognostic factors for recurrence in advanced stage uterine serous carcinoma (USC) patients.

Methods: Patients with 2009 International Federation of Gynecology and Obstetrics stage III&IV uterine serous carcinoma were enrolled from 4 gynecologic oncology centers and a study group was created. Response to therapy was evaluated according to the WHO criteria. Progression-free survival (PFS) and overall survival (OS) estimates were determinated by using the Kaplan-Meier method. Survival curves were compared with the log-rank test. Multivariate analysis was performed using the Cox proportional hazards model.

Results: Entire cohort included 63 patients. Median age of cohort was 64 years. Thirty-five (55.6 %) patients were stage IV. Lymphadenectomy was performed in 57 (90.5 %) patients and lymph node metastasis was positive in 45 (71.4 %) patients. Maximal cytoreduction (no residue tumor) was achieved in 53 (84.1 %) patients. However, optimal cytoreduction (residue tumor ≤1 cm) was achieved in 6 (9.5 %) patients and suboptimal cytoreduction (residue tumor >1 cm) was achieved in 3 (4.8 %) patients. Median follow-up time was 19 (range;1-152) months. Complete clinical response was obtained in 58 (92.1 %) patients after standard adjuvant therapy. Disease failure was detected in 25 patients. Study group had a 2-year PFS of 51 % and 2-year OS of 80 %. On multivariate analysis, performing lymphadenectomy was an independent prognostic factor for PFS (Odds ratio: 24.794, 95 % Confidence Interval: 4.214-145.869; p < 0.001).

Conclusion: Lymphadenectomy should be a part of the standard surgical therapy in advanced stage USC.
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http://dx.doi.org/10.1016/j.jogoh.2021.102063DOI Listing
May 2021

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

Arch Gynecol Obstet 2021 Aug 3;304(2):475-483. 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
August 2021

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

Gynecol Oncol 2021 03 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

Retrospective Analysis of Pure Ovarian Immature Teratoma in Patients Aged 15-39 Years: A Turkish Multicenter Study.

J Adolesc Young Adult Oncol 2020 Dec 9. Epub 2020 Dec 9.

Division of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey.

To evaluate the clinicopathological characteristics and surgical outcomes in patients with pure ovarian immature teratomas (POITs). In this multicenter study, a retrospective review was made of the databases of six Gynecology Oncology Departments in Turkey to identify patients with POITs who had undergone surgery between 1993 and 2019. Evaluation was made of 48 patients with a median age at diagnosis of 22.5 years (range, 15-37 years). In 40 (83%) patients, stage I was determined and in eight patients, an advanced stage (IIIB, IIIC, and IVB) was determined. Tumors were found to be grade I in 17 (35.4%) cases, grade II in 12 (25%), and grade III in 19 (39.6%). Fertility-sparing surgery was applied to 42 (87.5%) patients and radical surgery to 6 (12.5%). The median follow-up was 60 months (range, 3-246 months). Recurrence was seen in seven patients, all with grade III tumors. In the final pathological examination of recurrent tumors, mature teratoma was reported in five patients, and immature teratoma in one patient. Salvage surgery was not performed in one patient as the tumor was unresectable and so a regimen of bleomycin, etoposide, and cisplatin (BEP) was administered. POITs are rare tumors seen at a young age, and benign or malignant relapse can be seen in these tumors. In this cohort, the malignant recurrence rate was 4.1%, and the benign recurrence rate was 10.4%. All the recurrences were in grade III tumors. Benign recurrences can be treated with surgery alone and the malignant group should be treated with surgery followed by chemotherapy.
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http://dx.doi.org/10.1089/jayao.2020.0155DOI Listing
December 2020

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer.

Int J Gynecol Cancer 2020 09 11;30(9):1269-1277. Epub 2020 Aug 11.

Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Background: Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse.

Methods: We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group.

Results: Mean age was 48.3 years (range; 23-83) while the mean BMI was 25.7 kg/m (range; 15-49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07; 95% CI, 1.35 to 3.15; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76; 95% CI, 1.75 to 4.33; P<0.001) and those without the use of a uterine manipulator had similar disease-free-survival to the open surgery group (HR, 1.58; 95% CI, 0.79 to 3.15; P=0.20). Moreover, patients that underwent minimally invasive surgery with protective vaginal closure had similar rates of relapse to those who underwent open surgery (HR, 0.63; 95% CI, 0.15 to 2.59; P<0.52).

Conclusions: Minimally invasive surgery in cervical cancer increased the risk of relapse and death compared with open surgery. In this study, avoiding the uterine manipulator and using maneuvers to avoid tumor spread at the time of colpotomy in minimally invasive surgery was associated with similar outcomes to open surgery. Further prospective studies are warranted.
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http://dx.doi.org/10.1136/ijgc-2020-001506DOI Listing
September 2020

Performing gynecologic cancer surgery during the COVID-19 pandemic in Turkey: A multicenter retrospective observational study.

Int J Gynaecol Obstet 2020 Oct 11;151(1):33-38. Epub 2020 Aug 11.

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

Objective: To report the perioperative outcomes of 200 patients with gynecologic cancer who underwent surgery during the Novel Coronavirus Disease (COVID-19) pandemic and the safety of surgical approach.

Methods: Data of patients operated between March 10 and May 20, 2020, were collected retrospectively. Data were statistically analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows v. SP21.0.

Results: Data of 200 patients were included. Their mean age was 56 years. Of the patients, 54% (n=108), 27.5% (n=55), 12.5% (n=25), and 2% (n=4) were diagnosed as having endometrial, ovarian, cervical, and vulvar cancer, respectively. Of them, 98% underwent non-emergent surgery. A minimally invasive surgical approach was used in 18%. Stage 1 cancer was found in 68% of patients. Surgeons reported COVID-related changes in 10% of the cases. The rate of postoperative complications was 12%. Only two patients had cough and suspected pneumonic lesions on thoracic computed tomography postoperatively, but neither was positive for COVID-19 on polymerase chain reaction testing.

Conclusion: Based on the present findings, it is thought that gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to the measures. Postponement or non-surgical management should only be considered in patients with documented infection. Gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to measures. Only 1% of patients developed COVID-19-related symptoms during the postoperative follow-up period.
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http://dx.doi.org/10.1002/ijgo.13296DOI Listing
October 2020

A nomogram for decision-making of completion surgery in endometrial cancer diagnosed after hysterectomy.

Arch Gynecol Obstet 2019 09 27;300(3):693-701. Epub 2019 Jun 27.

Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey.

Objective: Extrauterine tumor spread is one of the essential determinants of disease outcome in endometrial cancer. However; more than 30% of patients still undergo incomplete surgery at the initial attempt. Strategies regarding the management of patients with incompletely staged early-stage disease or patients with undebulked advanced-stage disease remain controversial. Depending on postoperative uterine features and findings on imaging, patients may be put on observation or receive adjuvant therapy or undergo re-staging or debulking surgery followed by adjuvant therapy. To identify patients who would most benefit from a completion surgery, either for restaging or for cytoreduction, we developed a nomogram for estimation of extrauterine disease based on findings of final hysterectomy specimen.

Methods: Data of 336 patients whose extrauterine disease status was known were analyzed. A nomogram was constructed using patient characteristics including age, grade, myometrial invasion, lymphovascular space involvement, cervical involvement, and peritoneal cytology. The nomogram was internally validated in terms of discrimination, calibration and overall performance.

Results: The nomogram showed good performance accuracy with an area under the receiver operating characteristic curve of 0.870, a specificity of 95.5%, and a positive predictive value of 73.9%. Decision curve analysis revealed that the use of the nomogram in decision-making for completion surgery leads to the equivalent of a net 18 true-positive results per 100 patients without an increase in the number of false-positive results.

Conclusions: Estimation of extrauterine disease from final hysterectomy specimen is possible with high predictive performance using the nomogram developed. The nomogram may help clinicians in decision-making for management of incomplete surgeries.
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http://dx.doi.org/10.1007/s00404-019-05223-8DOI Listing
September 2019

Stanniocalcin-2 May Be a Potentially Valuable Prognostic Marker in Endometrial Cancer: a Preliminary Study.

Pathol Oncol Res 2019 Apr 19;25(2):751-757. Epub 2019 Jan 19.

Department of Gynecologic Oncology, Akdeniz University School of Medicine, Dumlupinar Boulevard, H-Block, K:1, 07059, Konyaalti, Antalya, Turkey.

In the current study, we primarily aimed to investigate stanniocalcin-2 (STC) protein expression pattern in hysterectomy specimens from patients with endometrioid type endometrial cancer (EC) using immunohistochemistry. Secondly, in order to clarify its prognostic impact, we examined relationships of the expression levels of STC with clinicopathologic features and outcome of patients. Histopathology slides of 49 patients were stained with the monoclonal mouse antibody targeting STC protein. The expression levels of STC were classified based on three-tiered semiquantitative scheme: negative expression, expression level of 0; low-expression, expression level of 1+; and high-expression, expression levels of 2+ and 3+. Recurrence-free survival (RFS) was used as the primary prognostic outcome. Immunohistochemical analysis revealed that 73.5% of tissue samples exhibited positive staining with STC. The intensity of staining with STC was weak in 40.8%, moderate in 22.4%, and strong in 10.2%. Thirty-eight percent of samples showed negative expression; 18.4%, low-expression (1+); and 42.8%, high-expression (2 to 3+). High-expression of STC was significantly associated with grade 2-3 tumors (p = 0.026) and disease recurrence (p = 0.013). Multivariate analysis revealed that both the tumor grade and STC were independent predictors of disease recurrence. Kaplan-Meier analyses confirmed that patients with high-expression of STC had a significantly poorer RFS than those with negative or low STC expression (p = 0.037); although overall survival did not differ with respect to expression levels of STC (p = 0.148). In conclusion, high-expression of STC is a negative prognostic factor, associated with increased risk of recurrence in endometrioid EC.
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http://dx.doi.org/10.1007/s12253-018-00576-yDOI Listing
April 2019

Is routine ECC necessary in patients with HPV16 and normal cytology?

Diagn Cytopathol 2018 Dec 24;46(12):1031-1035. Epub 2018 Oct 24.

Department of Gynecology and Obstetrics, Antalya Teaching and Research Hospital, Antalya, Turkey.

Background: In the present study, we primarily aimed to correlate the colposcopy results of patients with human papillomavirus (HPV) positivity and abnormal cervical screening results. Secondarily, we attempted to define the role of endocervical curettage (ECC) in the colposcopic evaluation of patients who had normal cytology and HPV16, which is the most carcinogenic HPV type.

Methods: This was a retrospective study analyzing the data of patients who had colposcopies between January 2015 and May 2016 in the Gynecological Oncology clinic of a single tertiary center. The data were evaluated to identify the pathologies in patients with HPV positivity and abnormal cervical screening results. A Colposcopic examination database was evaluated to obtain information regarding the cervical transformation zone (TZ), which was divided into three types by the International Federation for Cervical Pathology and Colposcopy. The binary variables were reported as counts and percentages.

Results: A total of 1049 patients were included in the analysis. The median age of the patients was 43 (range: 21-79). Cervical biopsies, ECC results, or both revealed cervical intraepithelial neoplasia 2+ (CIN2+: CIN2, CIN3, and invasive cancer) lesions in 22% (70/322) of the patients with HPV16 positivity, while this ratio was 8% (6/78) for patients with HPV18. CIN2+ lesions were detected in the 2.5% of patients with HPV positivity for types other than 16 and 18, as well as normal cytology. In the group of patients with HPV 16 and normal cytology, CIN2+ results were observed in the ECC of 11% of the patients whose colposcopy was normal regardless of the TZ type. Ten of the patients had invasive cancer.

Conclusion: The current study provides evidence for the possible role of routine ECC in patients with HPV16, normal cytology, and a normal colposcopy.
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http://dx.doi.org/10.1002/dc.24096DOI Listing
December 2018

The clinical impact of serous tubal intraepithelial carcinoma on outcomes of patients with high-grade serous carcinoma of the ovary, fallopian tube, and peritoneum.

J Cancer Res Ther 2018 Apr-Jun;14(3):587-592

Department of Pathology, Division of Gynecopathology, Akdeniz University School of Medicine, Antalya, Turkey.

Aims: To investigate whether the presence of serous tubal intraepithelial carcinoma (STIC) is associated with clinical outcomes in a nonselected (unknown BRCA status) cohort of patients with a high-grade serous carcinoma (HGSC) of the ovary, fallopian tube, and peritoneum.

Settings And Design: A prospective case-series with planned data collection.

Subjects And Methods: The study was conducted in a total of 131 patients, who underwent primary cytoreductive surgery between 2007 and 2012. Histological examination of the fallopian tubes included the "sectioning and extensively examining the fimbriated end" protocol. The diagnosis of STIC was based on the combination of morphology and immunohistochemistry. The patients were divided into two groups according to the absence or presence of STIC and compared clinicopathologically.

Statistical Analysis Used: Analyses were performed using PASW 18 (SPSS/IBM, Chicago, IL, USA) software. The primary outcome was progression-free survival (PFS), and the secondary outcome was overall survival (OS).

Results: STIC was identified in 20.6% of patients. Median follow-up time was 49.5 months for the STIC-positive group and 38.0 months for the STIC-negative group. Study groups were comparable in terms of clinicopathological characteristics with the exception that patients with STIC had less lymph node involvement (55.0% vs. 65.4%, P = 0.001), and more diagnosis of primary tubal carcinoma (29.6% vs. 3.8%, P = 0.001) compared to those without STIC. No statistically significant differences in terms of PFS (P = 0.462) and OS (P = 0.501) were observed between the groups.

Conclusions: The absolute identification of the origin of tumor cell does not seem to significantly affect the clinical course of the patients with HGSC.
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http://dx.doi.org/10.4103/0973-1482.172130DOI Listing
November 2018

Impact of coexistent adenomyosis on outcomes of patients with endometrioid endometrial cancer: a propensity score-matched analysis.

Tumori 2018 Jan-Feb;104(1):60-65

1 Department of Gynecologic Oncology, Akdeniz University School of Medicine, Antalya - Turkey.

Purpose: Despite the common occurrence of adenomyosis in endometrial cancer (EC), there is a paucity and conflict in the literature regarding its impact on outcomes of patients. We sought to compare outcomes of patients with endometrioid type EC with or without adenomyosis.

Methods: A total of 314 patients were included in the analysis. Patients were divided into 2 groups according to the presence or absence of adenomyosis. Adenomyosis was identified in 79 patients (25.1%). A propensity score-matched comparison (1:1) was carried out to minimize selection biases. The propensity score was developed through multivariable logistic regression model including age, stage, and tumor grade as covariates. After performing propensity score matching, 70 patients from each group were successfully matched. Primary outcome of the study was disease-free survival (DFS), and the secondary outcomes were overall survival (OS) and disease-specific survival (DSS).

Results: Median follow-up time was 61 months for the adenomyosis positive group and 76 months for the adenomyosis negative group. There were no statistically significant differences in 3- and 5-year DFS, OS, and DSS rates between the 2 groups. Five-year DFS was 92% vs 88% (hazard ratio [HR] 1.54 [0.56-4.27]; p = 0.404), 5-year OS was 94% vs 92% (HR 1.60 [0.49-5.26]; p = 0.441), and 5-year DSS was 94% vs 96% (HR 2.51 [0.46-13.71]; p = 0.290) for patients with and without adenomyosis, respectively.

Conclusions: Coexistent adenomyosis in EC is not a prognostic factor and does not impact survival outcomes.
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http://dx.doi.org/10.5301/tj.5000698DOI Listing
May 2018

Relationships of nuclear, architectural and International Federation of Gynecology and Obstetrics grading systems in endometrial cancer.

J Turk Ger Gynecol Assoc 2018 Mar 26;19(1):17-22. Epub 2017 Oct 26.

Department of Gynecologic Oncology, Akdeniz University School of Medicine, Antalya, Turkey.

Objective: To examine correlations among nuclear, architectural, and International Federation of Gynecology and Obstetrics (FIGO) grading systems, and their relationships with lymph node (LN) involvement in endometrioid endometrial cancer.

Material And Methods: Histopathology slides of 135 consecutive patients were reviewed with respect to tumor grade and LN metastasis. Notable nuclear atypia was defined as grade 3 nuclei. FIGO grade was established by raising the architectural grade (AG) by one grade when the tumor was composed of cells with nuclear grade (NG) 3. Correlations between the grading systems were analyzed using Spearman's rank correlation coefficients, and relationships of grading systems with LN involvement were assessed using logistic regression analysis.

Results: Correlation analysis revealed a significant and strongly positive relationship between FIGO and architectural grading systems (r=0.885, p=0.001); however, correlations of nuclear grading with the architectural (r=0.535, p=0.165) and FIGO grading systems (r=0.589, p=0.082) were moderate and statistically non-significant. Twenty-five (18.5%) patients had LN metastasis. LN involvement rates differed significantly between tumors with AG 1 and those with AG 2, and tumors with FIGO grade 1 and those with FIGO grade 2. In contrast, although the difference in LN involvement rates failed to reach statistical significance between tumors with NG 1 and those with NG 2, it was significant between NG 2 and NG 3 (p=0.042). Although all three grading systems were associated with LN involvement in univariate analyses, an independent relationship could not be established after adjustment for other confounders in multivariate analysis.

Conclusion: Nuclear grading is significantly correlated with neither architectural nor FIGO grading systems. The differences in LN involvement rates in the nuclear grading system reach significance only in the setting of tumor cells with NG 3; however, none of the grading systems was an independent predictor of LN involvement.
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http://dx.doi.org/10.4274/jtgga.2017.0004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838773PMC
March 2018

The Impact of Surgical Staging on the Prognosis of Mucinous Borderline Tumors of the Ovaries: A Multicenter Study.

Anticancer Res 2017 10;37(10):5609-5616

Department of Gynecology and Gynecologic Oncology, Zekai Tahir Burak Education and Research Hospital, Ankara, Turkey.

Background/aim: The purpose of this study was to prove the effect of complete surgical staging of patients with mucinous borderline ovarian tumors (mBOTs) especially appendectomy on progression-free survival (PFS) and overall survival (OS).

Patients And Methods: The database of 14 gynecological oncology departments from Turkey and Germany were comprehensively searched for women who underwent primary surgery for an ovarian tumor between January 1, 1998, and December 31, 2015, and whose final diagnosis was mBOT.

Results: A total of 364 patients with mBOT with a median age of 43.1 years were included in this analysis. The median OS of all patients was 53.1 months. The majority of cases had Stage IA (78.6%). In univariate and multivariate analyses, radical surgery, omentectomy, appendectomy, lymphadenectomy, and adding adjuvant chemotherapy were not independent prognostic factors for PFS and OS. Furthermore, FIGO stage (≥IC vs.
Conclusion: Patients with conservative surgery do not have higher recurrence rates. Fertility-sparing surgery should be considered in the reproductive age group. Detailed surgical staging including lymphadenectomy, appendectomy, and omentectomy does not have an impact on survival rates.
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http://dx.doi.org/10.21873/anticanres.11995DOI Listing
October 2017

Prognostic risk factors for lymph node involvement in patients with endometrial cancer.

Turk J Obstet Gynecol 2017 Mar 15;14(1):52-57. Epub 2017 Mar 15.

Akdeniz University Faculty of Medicine, Department of Gynecopathology, Antalya, Turkey.

Objective: We aimed to analyze variables affecting lymph node (LN) involvement and to assess the need for systematic lymphadenectomy in patients with endometrial cancer (EC).

Materials And Methods: A single centre retrospective analysis was conducted in a total of 128 consecutive patients with EC who underwent systematic pelvic or combined pelvic and paraaortic lymphadenectomy between 2009 and 2012. Mann-Whitney U, chi-square, and Fisher's exact test were used for univariate analyses when appropriate. Variables with a p value <0.05 in the univariate analysis were included into a multivariate logistic regression analysis. The effects of variables on LN involvement are reported using adjusted odds ratios (ORs) and 95% confidence intervals (CI).

Results: In univariate analysis, grade 2-3, tumor size ≥3 cm, deep (≥50%) myometrial invasion, presence of cervical, adnexal or omental involvement, positive peritoneal cytology, open surgical approach (laparotomy), combined pelvic and paraaortic lymphadenectomy and number of total LNs removed (>30) were found associated with LN involvement. However, the number of total LNs removed (>30) was the only independent variable that predict LN involvement in multivariate analysis [OR: 15.08; 95% CI: (1.28-177.59); p=0.03].

Conclusion: This study demonstrates that the more LNs removed during staging of EC, the greater the probability of finding LN metastasis.
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http://dx.doi.org/10.4274/tjod.52385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5558318PMC
March 2017

What is the impact of stromal microinvasion on oncologic outcomes in borderline ovarian tumors? A multicenter case-control study.

Arch Gynecol Obstet 2017 Nov 2;296(5):979-987. Epub 2017 Sep 2.

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

Purpose: To investigate clinicopathological characteristics and oncological outcome of women with microinvasive BOTs.

Methods: A retrospective multicenter case-control study was conducted on 902 patients with BOT, who underwent surgery from January 2002 to December 2015 at six participating gynecologic oncology centers from Turkey. Among 902 patients, 69 had microinvasive BOT. For every patient with microinvasive BOT, two controls were randomly selected from another database based on decade of age and stage of disease at diagnosis. The clinical-pathological characteristics and oncological outcomes were compared between BOT patients with and without stromal microinvasion. Risk factors for poor oncological outcomes were investigated in a multivariate analysis model. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method.

Results: Patients with microinvasive BOT had a significantly higher rate of recurrence than patients without microinvasive BOT (17.4 vs 7.8%, OR 3.55, %95 CI 1.091-11.59, p = 0.03). Stage at diagnosis (stage I versus II/III) and type of surgery (cystectomy versus others) were found as other significant prognostic factors for recurrence in multivariate analysis (OR 8.63, %95 CI 2.48-29.9, p = 0.001 and OR 19.4, %95 CI 3.59-105.6, p = 0.001, respectively). Stromal microinvasion was found as a prognostic factor for significantly shorter DFS (26.7 vs 11.9 months, p = 0.031, log rank). However, there was no significant difference in OS between two groups (p = 0.99, log rank).

Conclusion: Stromal microinvasion is significantly associated with decreased DFS. In addition, our study confirms that the risk of recurrence is higher in patients with microinvasive BOT.
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http://dx.doi.org/10.1007/s00404-017-4496-4DOI Listing
November 2017

A Rare Case: Struma Ovarii in a 14-Year-Old Girl.

J Adolesc Young Adult Oncol 2018 02 31;7(1):134-136. Epub 2017 Jul 31.

1 Department of Gynecology and Obstetrics, Antalya Training and Research Hospital, Sağlık Bilimleri University , Antalya, Turkey .

Ovarian tumors presented with ovarian mass in childhood and adolescence are uncommon but an important part of gynecological cases. Struma ovarii is one of the rare cystic benign ovarian tumors that is observed predominantly in women who are between the ages of 40 and 60 years old. It is extremely rare in adolescents. Herein, we present a 14-year-old adolescent girl with struma ovarii who presented to the emergency room with abdominal pain.
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http://dx.doi.org/10.1089/jayao.2017.0033DOI Listing
February 2018

Comparison Of Early-Stage High-Grade Serous Primary Fallopian Tube Cancers and Epithelial Ovarian Cancers: A Multicenter Study.

Oncol Res Treat 2017 21;40(4):203-206. Epub 2017 Mar 21.

Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Izmir, Turkey.

Introduction: We compared the disease free-survival (DFS) and overall survival (OS) rates of patients with high-grade serous primary fallopian tube cancer (HG-sPFTC) and high-grade serous epithelial ovarian cancer (HG-sEOC).

Methods: 22 early-stage cancer patients (International Federation of Gynecology and Obstetrics (FIGO) stages I-II) with HG-sPFTC were retrospectively evaluated. In addition, 44 control patients diagnosed with HG-sEOC were matched to these patients with respect to tumor stage at diagnosis. All patients underwent complete surgical staging, followed by adjuvant chemotherapy. Kaplan-Meier curves were used to generate survival data.

Results: The mean age of HG-sPFTC patients was 59.4 ± 6.2 years, and that of HG-sEOC patients 55.2 ± 11.0 years (p = 0.002). All patients underwent 6 cycles of platinum-based adjuvant chemotherapy. All operations were optimal. The 5-year DFSs were 77.3% for HG-sPFTC patients and 75% for HG-sEOC patients (p = 1.00).The 5-year OS rates were 81.8% in women with HG-sPFTC and 77.3% in those with HG-sEOC (p = 0.75).

Conclusion: The DFS and OS rates of patients with early-stage (FIGO stages I and II) HG-sPFTC and HG-sEOC were similar. The surgical and adjuvant therapy management of these malignancies should be similar.
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http://dx.doi.org/10.1159/000458440DOI Listing
November 2017

Assessment of circulating betatrophin concentrations in lean glucose-tolerant women with polycystic ovary syndrome.

J Obstet Gynaecol 2017 Jul 20;37(5):633-638. Epub 2017 Mar 20.

b Department of Biochemistry , Antalya Training and Research Hospital , Antalya , Turkey.

The aims of the current study were to investigate the betatrophin levels in lean glucose-tolerant women with polycystic ovary syndrome (PCOS), and to explore the relationships between these levels and antropometric, hormonal and metabolic parameters. The study population consisted of 50 lean (body mass index [BMI] < 25 kg/m) women diagnosed with PCOS using the Rotterdam criteria, and 60 age- and BMI-matched healthy controls without any features of clinical or biochemical hyperandrogenism. Before recruitment, glucose tolerance was evaluated in all of the subjects using the 2-h 75 g oral glucose-tolerance test, and only those exhibiting normal glucose tolerance were enrolled. Serum betatrophin levels were significantly higher in women with PCOS (median 322.3; range 44.7-1989.3 ng/L) compared to the controls (median 199.9; range 6.2-1912.9 ng/L; p = .005). In the control group, no significant correlation was evident between betatrophin levels and clinical or biochemical parameters. In the PCOS group, betatrophin levels were positively correlated with prolactin levels (r = .286, p = .046) and negatively correlated with BMI (r = -.283, p = .049), waist/hip ratio (r = -.324, p = .023), and low-density lipoprotein cholesterol levels (r = -.385, p = .006). Impact statement What is already known on this subject: Several studies have suggested that primary alteration in beta-cell function is a pathophysiological feature of PCOS, and insulin resistance is the most significant predictor of beta-cell dysfunction independent of obesity. Betatrophin is a circulating protein that is primarily expressed in the liver in humans. Early experimental investigations demonstrated that overexpression of betatrophin significantly promoted pancreatic beta-cell proliferation, insulin production and improved glucose tolerance. Few studies have investigated the association between PCOS and betatrophin. However, in contrast to our study, the authors included overweight/obese patients and glucose tolerance was not evaluated before recruitment. What the results of this study add: Our results showed that serum betatrophin levels were significantly higher in lean glucose-tolerant PCOS women than in age- and BMI-matched healthy controls. What are the implications of these findings for clinical practice and/or further research: Elevated betatrophin levels in PCOS women, in the absence of obesity and glucose intolerance, may reflect a compensatory mechanism in order to counteract metabolic syndrome-related risk factors.
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http://dx.doi.org/10.1080/01443615.2017.1286464DOI Listing
July 2017

Correlation of Minimum Apparent Diffusion Coefficient and Maximum Standardized Uptake Value of the Primary Tumor with Clinicopathologic Characteristics in Endometrial Cancer.

Mol Imaging Radionucl Ther 2017 Feb;26(1):24-32

Akdeniz University Faculty of Medicine, Department of Nuclear Medicine, Antalya, Turkey Phone: +90 532 638 06 54 E-mail:

Objective: To explore the correlation of the primary tumor's maximum standardized uptake value (SUV) and minimum apparent diffusion coefficient (ADC) with clinicopathologic features, and to determine their predictive power in endometrial cancer (EC).

Methods: A total of 45 patients who had undergone staging surgery after a preoperative evaluation with F-fluorodeoxyglucose (FDG) positron emission tomography/computerized tomography (PET/CT) and diffusion-weighted magnetic resonance imaging (DW-MRI) were included in a prospective case-series study with planned data collection. Multiple linear regression analysis was used to determine the correlations between the study variables.

Results: The mean ADC and SUV values were determined as 0.72±0.22 and 16.54±8.73, respectively. A univariate analysis identified age, myometrial invasion (MI) and lymphovascular space involvement (LVSI) as the potential factors associated with ADC while it identified age, stage, tumor size, MI, LVSI and number of metastatic lymph nodes as the potential variables correlated to SUV. In multivariate analysis, on the other hand, MI was the only significant variable that correlated with ADC (p=0.007) and SUV (p=0.024). Deep MI was best predicted by an ADC cutoff value of ≤0.77 [93.7% sensitivity, 48.2% specificity, and 93.0% negative predictive value (NPV)] and SUV cutoff value of >20.5 (62.5% sensitivity, 86.2% specificity, and 81.0% NPV); however, the two diagnostic tests were not significantly different (p=0.266).

Conclusion: Among clinicopathologic features, only MI was independently correlated with SUV and ADC. However, the routine use of F-FDG PET/CT or DW-MRI cannot be recommended at the moment due to less than ideal predictive performances of both parameters.
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http://dx.doi.org/10.4274/mirt.30306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350502PMC
February 2017

Borderline ovarian tumors: clinical characteristics, management, and outcomes - a multicenter study.

J Ovarian Res 2016 Oct 18;9(1):66. Epub 2016 Oct 18.

Department of Gynecology and Gynecologic Oncology, Antalya Education and Research Hospital, Antalya, Turkey.

Background: The optimal surgical management and staging of borderline ovarian tumors (BOTs) are controversial. Institutions have different surgical approaches for the treatment of BOTs. Here, we performed a retrospective review of clinical characteristics, surgical management and surgical outcomes, and sought to identify variables affecting disease-free survival (DFS) and overall survival (OS) in patients with BOTs.

Methods: A retrospective review of ten gynecological oncology department databases in Turkey was conducted to identify patients diagnosed with BOTs. The effects of type of surgery, age, stage, surgical staging, complete versus incomplete staging, and adjuvant chemotherapy were examined on DFS and OS.

Results: In total, 733 patients with BOTs were included in the analysis. Most of the staged cases were in stage IA (70.4 %). In total, 345 patients underwent conservative surgeries. Recurrence rates were similar between the conservative and radical surgery groups (10.5 % vs. 8.7 %). Furthermore we did not find any difference between DFS (HR = 0.96; 95 % confidence interval, CI = 0.7-1.2; p = 0.576) or OS (HR = 0.9; 95 % CI = 0.8-1.1; p = 0.328) between patients who underwent conservative versus radical surgeries. There was also no difference in DFS (HR = 0.74; 95 % CI = 0.8-1.1; p = 0.080) or OS (HR = 0.8; 95 % CI = 0.7-1.0; p = 0.091) between complete, incomplete, and unstaged patients. Furthermore, receiving adjuvant chemotherapy (CT) for tumor stage ≥ IC was not an independent prognostic factor for DFS or OS.

Conclusions: Patients undergoing conservative surgery did not show higher recurrence rates; furthermore, survival time was not shortened. Detailed surgical staging, including lymph node sampling or dissection, appendectomy, and hysterectomy, were not beneficial in the surgical management oF BOTs.
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http://dx.doi.org/10.1186/s13048-016-0276-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070357PMC
October 2016

Liver recurrence in endometrial cancer: a multi-institutional analysis of factors predictive of postrecurrence survival.

Clin Exp Metastasis 2016 10 23;33(7):707-15. Epub 2016 Jun 23.

Department of Gynecologic Oncological Surgery, Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey.

Predictive factors for survival following liver metastasis in endometrial cancer (EC) have not been studied to date. It is expected that patients who initially presented with liver metastasis or developed liver metastasis as the subsequent metastatic site of progressive disease are likely to have poor outcomes. However, patients developing liver metastasis as the first site of recurrence may have a chance of benefiting from the salvage therapies. Therefore, we aimed to determine factors influencing postrecurrence survival in EC patients who developed liver metastasis as the first site of recurrence. Patients with EC who underwent primary surgery at three centers between 1993 and 2013 were reviewed. Liver recurrence was defined as documentation of parenchymal liver metastasis either by radiologically or biopsy, after a disease-free interval of ≥3 months. Patients with liver metastasis at presentation, or liver metastasis as the subsequent metastatic site of progressive disease were excluded. Forty-six patients were identified. Median time to liver recurrence was 12 months, with 91.3 % of recurrences detected within 3 years. Most patients (73.9 %) had liver recurrence concomitant with extra-hepatic disease. Median survival after the diagnosis of liver recurrence was 9 months. While in univariate analysis, time to liver recurrence (p < 0.001) and presence of concomitant extra-hepatic metastasis (p = 0.048) were potential predictors of survival, multivariate analysis revealed that time to liver recurrence (p < 0.001) was the only independent predictor. This criterion may be used as a marker for stratifying patients into different prognostic risk groups and for selection of patients for salvage therapies.
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http://dx.doi.org/10.1007/s10585-016-9806-xDOI Listing
October 2016

Validation of Revised FIGO Staging Classification for Cancer of the Ovary, Fallopian Tube, and Peritoneum Based on a Single Histological Type.

Int J Gynecol Cancer 2016 07;26(6):1012-9

*Division of Gynecologic Oncological Surgery, Department of Obstetrics and Gynecology, Antalya Research and Training Hospital; †Division of Gyneco-pathology, Department of Pathology, ‡Departmentof Biostatistics and Medical Informatics, and §Division of Gynecologic Oncological Surgery, Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey.

Objective: This study aimed to evaluate the prognostic significance of revised International Federation of Gynecology and Obstetrics (FIGO2013) staging classification for cancer of the ovary, fallopian tube, and peritoneum in patients exhibiting high-grade serous histology.

Methods: Clinical records of patients with high-grade serous carcinoma who underwent primary surgery between 2007 and 2012 were reviewed retrospectively. Patients were reclassified according to the FIGO2013 criteria. Progression-free survival (PFS) and overall survival (OS) were calculated for each stage using Kaplan-Meier estimates and compared with the log-rank test.

Results: In total, 125 patients were included in the analysis. The distribution of the study cohort according to the revised classification was as follows; stage I, 6 patients; stage II, 9 patients; stage III, 85 patients; and stage IV, 25 patients. Median follow-up time was 36 months (95% confidence interval [CI], 3-110). The median PFS and OS were 14 months (95% CI, 12.4-15.6) and 60 months (95% CI, 47.0-72.9), respectively. Both PFS and OS were significantly different among stages I, II, III, and IV (P < 0.01). Subgroup analyses for stage III disease also revealed significant differences in survival. The median PFS for stages IIIA1, IIIB, and IIIC was 56, 46, and 16 months, respectively (P < 0.01), and the median OS was 104, 95, and 60 months, respectively (P = 0.03). The outcomes of patients with stage IV disease differed slightly but nonsignificantly according to new substages. The median PFS for stages IVA and IVB was 12 and 6 months, respectively (hazard ratio, 1.16; 95% CI, 0.48-2.79; P = 0.72), and the median OS was 41 and 24 months, respectively (hazard ratio, 1.62; 95% CI, 0.58-4.55; P = 0.35). The study sample was insufficient in size for subgroup analyses in stages I and II.

Conclusions: The revised FIGO2013 staging system is highly prognostic for discriminating outcomes of patients with high-grade serous carcinoma across stages I to IV, in subgroups of stage III, but not in subgroups of stage IV.
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http://dx.doi.org/10.1097/IGC.0000000000000736DOI Listing
July 2016

Robotic Compartment-Based Radical Surgery in Early-Stage Cervical Cancer.

Case Rep Surg 2016 18;2016:4616343. Epub 2016 Apr 18.

Department of Gynecologic Oncological Surgery, Akdeniz University School of Medicine, 07070 Antalya, Turkey.

A radical hysterectomy with pelvic lymphadenectomy is the recommended treatment option in patients with early-stage cervical cancer. Although various classifications were developed in order to define the resection margins of this operation, no clear standardization could be achieved both in the nomenclature and in the extent of the surgery. Total mesometrial resection (TMMR) is a novel procedure which aims to remove all components of the compartment formed by Müllerian duct in which female reproductive organs develop. TMMR differs from the conventional radical hysterectomy techniques in that its surgical philosophy, terminology, and partly resection borders are different. In this paper, a TMMR with therapeutic pelvic lymphadenectomy operation that we performed for the first time with robot-assisted laparoscopic (robotic) approach in an early-stage cervical cancer patient was presented. This procedure has already been described in open surgery by Michael Höckel and translated to the robotic surgery by Rainer Kimmig. Our report is the second paper, to our knowledge, to present the initial experience regarding robotic TMMR in the English literature.
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http://dx.doi.org/10.1155/2016/4616343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4852353PMC
May 2016

Immunohistochemical Analysis of E-Cadherin, p53 and Inhibin-α Expression in Hydatidiform Mole and Hydropic Abortion.

Pathol Oncol Res 2016 Jul 18;22(3):515-21. Epub 2015 Dec 18.

Department of Pathology, Antalya Training and Research Hospital, Antalya, Turkey.

The purpose of this study was to investigate the role of E-cadherin, p53, and inhibin-α immunostaining in the differential diagnosis of hydropic abortion (HA), partial hydatidiform mole (PHM), and complete hydatidiform mole (CHM). E-cadherin, p53, and inhibin-α protein expression patterns were investigated immunohistochemically using paraffin -embedded tissue sections from histologically diagnosed cases of HA (n = 23), PHM (n = 24), and CHM (n = 23). Expression patterns of these markers were scored semi-quantitatively according to the staining intensity, percentage of positive cells, and immunoreactivity score. Classification of cases was established on histologic criteria and supported by the molecular genotyping. Immunostaining allowed the identification of specific cell types with E-cadherin, p53, and inhibin-α expression in all cases. E-cadherin expression was detected on the cell surface of villous cytotrophoblasts. We observed a marked decline in the expression of E-cadherin from HAs to PHMs to CHMs. The p53-positive reaction was restricted to the nucleus of villous cytotrophoblasts. Significantly increased p53 expression was observed in CHMs, compared with HAs and PHMs. The expression of inhibin-α was localised in the cytoplasm of villous syncytiotrophoblasts, and the expression of this marker was significantly higher in PHMs and CHMs than HAs. In conclusion, immunohistochemical analysis of E-cadherin, p53, and inhibin-α expression could serve as a useful adjunct to conventional methods in the differential diagnosis of HA, PHM, and CHM.
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http://dx.doi.org/10.1007/s12253-015-0031-8DOI Listing
July 2016

Analysis of Metastatic Regional Lymph Node Locations and Predictors of Para-aortic Lymph Node Involvement in Endometrial Cancer Patients at Risk for Lymphatic Dissemination.

Int J Gynecol Cancer 2015 May;25(4):657-64

*Division of Gynecologic Oncological Surgery, Department of Obstetrics and Gynecology, and †Division of Gynecopathology, Department of Pathology, Akdeniz University Hospital, Antalya, Turkey.

Objective: The aim of this study was to provide detailed knowledge of the metastatic lymph node (LN) locations and to determine factors predicting para-aortic LN metastasis in endometrial cancer patients at risk (intermediate/high) for LN involvement.

Methods: A prospective case series with planned data collection was conducted in a total of 173 patients who treated with systematic pelvic para-aortic lymphadenectomy up to the renal vessels. All the LNs removed from pelvic and para-aortic basins—low or high according to the level of the inferior mesenteric artery—were evaluated separately. Logistic regression analyses were performed to determine the impact of variables on para-aortic metastasis.

Results: Lymph node metastasis was observed in 21.9% of the patients, pelvic LN involvement in 17.9%, para-aortic LN involvement in 15.0%, both pelvic and para-aortic LN involvement in 10.9%, and isolated para-aortic LN involvement in 4.0%. The most common metastatic LN locations were the external iliac (50.0%), obturator (50.0%), and low precaval regions (36.8%). The least common location of metastasis was the high precaval region (5.3%). Among patients with para-aortic LN metastasis, 42.3% had metastasis above the inferior mesenteric artery. The number of metastatic pelvic LNs greater than or equal to 2 was the only independent predictor of para-aortic metastasis in multivariate analysis (odds ratio, 23.38; 95% confidence interval, 1.35-403.99; P = 0.030), with 96.94% sensitivity, 95.87% specificity, 98.6% positive predictive value, and 97.0% negative predictive value.

Conclusions: The current study supports the idea that in patients at risk of LN involvement, the systematic lymphadenectomy should be performed up to the renal vessels due to the high rate of upper level involvement.
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http://dx.doi.org/10.1097/IGC.0000000000000392DOI Listing
May 2015

Prognostic Significance of Retroperitoneal Lymphadenectomy, Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Primary Fallopian Tube Carcinoma: A Multicenter Study.

Cancer Res Treat 2015 Jul 17;47(3):480-8. Epub 2014 Nov 17.

Department of Gynecologic Oncology, Ankara University School of Medicine, Ankara, Turkey.

Purpose: The purpose of this study is to evaluate the prognostic role of preoperative neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and the need for para-aortic lymphadectomy in patients with primary fallopian tube carcinoma (PFTC).

Materials And Methods: Ninety-one patients with a diagnosis of PFTC were identified through the gynecologic oncology service database of six academic centers. Clinicopathological, surgical, and complete blood count data were collected.

Results: In univariate analysis, advanced stage, suboptimal surgery, and NLR > 2.7 were significant prognostic factors for progression-free survival, whereas in multivariate analysis, only advanced stage and suboptimal surgery were significant. In addition, in univariate analysis, cancer antigen 125 ≥ 35 U/mL, ascites, advanced stage, suboptimal surgery, NLR > 2.7, PLR > 233.3, platelet count ≥ 400,000 cells/mm(3), staging type, and histological subtype were significant prognostic factors for overall survival (OS); however, in multivariate analysis, only advanced stage, suboptimal surgery, NLR > 2.7, and staging type were significant. Inclusion of pelvic and para-aortic lymphadenectomy in surgery showed significant association with longer OS, with a mean and median OS of 42.0 months and 35.5 months (range, 22 to 78 months), respectively, vs. 33.5 months and 27.5 months (range, 14 to 76 months), respectively, for patients who underwent surgery without para-aortic lymphadenectomy (hazard ratio, 3.1; 95% confidence interval, 1.4 to 5.7; p=0.002).

Conclusion: NLR (in both univariate and multivariate analysis) and PLR (only in univariate analysis) were prognostic factors in PFTC. NLR and PLR are inexpensive and easy tests to perform. In addition, patients with PFTC who underwent bilateral pelvic and para-aortic lymphadenectomy had longer OS.
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http://dx.doi.org/10.4143/crt.2014.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4506112PMC
July 2015

Survival analysis of pelvic lymphadenectomy alone versus combined pelvic and para-aortic lymphadenectomy in patients exhibiting endometrioid type endometrial cancer.

Oncol Lett 2015 Jan 31;9(1):355-364. Epub 2014 Oct 31.

Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncological Surgery, Akdeniz University Hospital, Antalya, Konyaaltı 07070, Turkey.

The therapeutic benefit of lymphadenectomy in patients exhibiting endometrial cancer (EC) remains controversial. The aim of the present study was to determine whether the addition of para-aortic lymphadenectomy to pelvic lymphadenectomy (PLND) improves survival in patients with endometrioid type EC. A single tertiary-center, retrospective analysis was conducted in a total of 186 patients who were surgically treated with either PLND alone (n=97) or combined pelvic and para-aortic lymphadenectomy (PPaLND; n=89). Adjuvant treatments were assigned according to the Gynecologic Oncology Group (GOG) risk of recurrence analysis. The primary endpoint of the present study was progression-free survival (PFS). The median follow-up time was 38 months (95% confidence interval, 36.47-42.90) for all patients. No statistically significant differences were identified between the two groups in terms of overall survival (OS), PFS or time to progression (TTP). Kaplan-Meier estimates of three-year OS, PFS and TTP for patients with low or low-intermediate risk were as follows: PLND, 100, 98.7 and 98.7%, respectively; and PPaLND, all 100%. The estimated three-year OS, PFS and TTP for patients with high or high-intermediate risk were as follows: PLND, 92.3, 81.3 and 81.3%; and PPaLND, 90.7, 77.1 and 80.9%, respectively. No statistically significant differences were detected in the three-year OS, PFS and TTP between the lymphadenectomy groups, regardless of the GOG risk of recurrence (PLND, 98.4, 95.3 and 95.3%; and PPaLND, 94.9, 87.1 and 89.4%). Therefore, the combination treatment, PPaLND did not provide any survival advantage over pelvic lymphadenectomy alone.
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http://dx.doi.org/10.3892/ol.2014.2653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246997PMC
January 2015
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