Preeclampsia,gestational hypertension and subsequent hypothyroidism

ObjectivesTo evaluate the effect of preeclampsia (PE) and gestational hypertension (GH) on subsequent hypothyroidism. Recent studies suggest that women with PE have increased risk for reduced thyroid function, but the association between PE and GH with overt hypothyroidism has not been examined.Study designTwo prospective population-based cohort studies, the Northern Finland Birth Cohorts 1966 and 1986, followed women who had PE (N = 955), GH (N = 1449) or were normotensive (N = 13531) during pregnancy. Finnish national registers were used to confirm subsequent hypothyroidism. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) estimated hypothyroidism risk when comparing women with PE or GH with normotensive women.Main outcome measuresPrimary hypothyroidism during follow-up of 20–40 years.ResultsThe subsequent prevalence of hypothyroidism was higher among women with PE (4.0%) and GH (4.5%) compared with normotensive women (3.5%), but the risk increase was not significant (aHR for PE 1.13, 95% CI 0.80–1.59 and aHR for GH 1.11, 95% CI 0.85–1.45).Subgroup analysis among nulliparous women revealed a significant association between late PE and subsequent hypothyroidism (aHR 1.82, 95% CI 1.04–3.19).Early or recurrent PE was not associated with hypothyroidism (aHR 0.93, 95% CI 0.46–1.81 and aHR 1.35, 95% CI 0.63–2.88, respectively).ConclusionsOverall, PE or GH during pregnancy was not significantly associated with subsequent hypothyroidism in Finnish women after 20–40 years of follow-up. However, late PE in nulliparous women was associated with a 1.8-fold increased risk of subsequent hypothyroidism, a finding that merits further study in other populations.     

Prognostic factors and outcomes in endometrial stromal sarcoma with the 2009 FIGO staging system: A multicenter review of 114 cases

Objective

To assess prognostic factors associated with disease-related survival in endometrial stromal sarcoma (ESS) using the 2009 FIGO staging system.

Methods

From January 1990 to January 2012, 114 patients with ESS were identified at the Samsung and Asan Medical Center and data were retrospectively analyzed.

Results

Ten (8.7%) patients died of the disease and 33 (28.9%) patients relapsed. The 5- and 10-year overall survival (OS) rates for the entire cohort were 92.6% and 87.1%, respectively, and the 5- and 10-year recurrence-free survival (RFS) rates were 71.8% and 52.1%, respectively. The estimated median survival after recurrence for the 33 patients whose tumors relapsed was 133 months (95% CI, 7.7–258.4), and 5-year survival after recurrence was 68.9%. Stage I (P = 0.006), estrogen and/or progesterone receptor (ER/PR) positivity (P = 0.0027), and no nodal metastasis (P = 0.033) were associated with a good prognosis for OS in the univariate analysis. Ovarian preservation was revealed to be an independent predictor for poorer RFS (HR, 6.5; 95% CI, 1.23–34.19; P = 0.027). Positivity for ER/PR (HR, 0.05; 95% CI, 0.006–0.4; P = 0.006) and cytoreductive resection of recurrent lesions (HR, 0.14; 95% CI, 0.02–0.93; P = 0.042) were independent predictors of better survival after recurrence.

Conclusions

Stage, expression of ER/PR, and nodal metastasis are significantly associated with OS in ESS. Bilateral salpingo-oophorectomy (BSO) as the primary treatment and cytoreductive resection of recurrent lesions should be considered for improving survival of patients with ESS.     

Possible candidate population for neoadjuvant chemotherapy in women with advanced ovarian cancer

ObjectiveTo examine trends and outcomes related to neoadjuvant chemotherapy (NACT) use for advanced ovarian cancer based on patient and tumor factors.MethodsThis retrospective cohort study queried the National Cancer Institute's Surveillance, Epidemiology, and End Results Program to examine women with stage III-IV high-grade serous ovarian carcinoma from 2010 to 2016. Propensity score inverse probability of treatment weighting was used to assess the age-, cancer stage-, and tumor extent-specific survival estimates related to NACT use.ResultsUtilization of NACT has significantly increased in older women (≥65 years; 48.4% relative increase), followed by stage IV disease (35.2% relative increase), and stage III disease (25.0% relative increase) (all, P-trend < 0.05). Women who received NACT had overall survival (OS) similar to those who had primary cytoreductive surgery (PCS) in older women (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.95–1.20, P = 0.284), stage IV disease (HR 0.96, 95%CI 0.84–1.10, P = 0.564), and more disease extent cases (T3/N1/M1, HR 1.06, 95%CI 0.84–1.32, P = 0.640). Moreover, NACT use was associated with decreased other cause mortality risk compared to PCS in the older women (sub-distribution HR 0.61, 95%CI 0.40–0.94, P = 0.025) and stage IV disease (sub-distribution HR 0.49, 95%CI 0.27–0.90, P = 0.021). In contrast, women who received NACT had decreased OS compared to those who had PCS in the younger group (HR 1.22, 95%CI 1.07–1.38, P = 0.004), stage III disease (HR 1.26, 95%CI 1.13–1.41, P < 0.001), and lesser disease extent cases (T3/N0/M0, HR 1.38, 95%CI 1.20–1.58, P < 0.001).ConclusionOur study suggests that survival effect of NACT for advanced ovarian cancer may differ based on patient and tumor factors. In older women, stage IV disease, and greater disease extent, NACT was associated with similar OS compared to PCS.     

Prognosis for advanced-stage primary peritoneal serous papillary carcinoma and serous ovarian cancer in Taiwan

ObjectiveTo compare the prognosis of patients with advanced-stage primary peritoneal serous papillary carcinoma (PSPC) or papillary serous ovarian cancer (PSOC).Materials and MethodsThis was a retrospective case–control study and included two study groups: one with stage III/IV PSPC (n = 38) patients and the other with PSOC (n = 53) patients. Patients were matched for histologic subtype (serous tumor), tumor stage, tumor grade, residual disease at the end of debulking surgery (primary or interval), and age (±5 years).ResultsMean age was significantly greater for patients with PSPC (63.03 ± 11.88 years) than for patients with PSOC (55.92 ± 12.56 years, p = 0.008). Optimal debulking surgery was performed initially in 71.9% of PSPC patients and 66.0% of PSOC patients. In addition, 93.9% of PSPC patients and 92.3% of PSOC patients were treated with platinum–paclitaxel chemotherapy. The frequency of high-grade tumors was significantly higher in the PSPC (100%) than in the PSOC group (68.3%; p < 0.001). Progression-free survival (PFS) was similar in the PSPC [median 12 months, 95% confidence interval (CI) 7.3–16.7] and PSOC groups (median 16.7 months, 95% CI 12.9–20.4; p = 0.470). Overall survival was shorter in the PSPC (median 62 months, 95% CI 19.6–104.4) than in the PSOC group (median 77.5 months, 95% CI 69.7–85.2; p = 0.006, log-rank statistic).ConclusionPFS was similar for advanced-stage PSPC and PSOC patients. Since the PSPC patients tended to be older and have more high-grade tumors, OS was shorter for PSPC than for POSC patients. Thus, management of the two types of cancer should not differ.     

Early-stage clear cell ovarian cancer compared to high-grade histological subtypes: An outcome exploratory analysis in two oncology centers

Objectiveadvanced stage clear cell ovarian cancer (CCOC) carries a higher risk of relapse and death compared to other histological subtypes. The prognosis of early-stage CCOC is controversial.MethodsEarly-stage high-grade OC patients from two Italian oncologic centers were included. Patients with early-stage CCOC were compared with those with high-grade endometrioid (HGE) and serous (HGS) OC in terms of relapse-free interval (RFI), cancer-specific survival (CSS) and post relapse cancer-specific survival (prCSS). The Cox proportional hazard model and the restricted mean survival time were used.ResultsBetween 1981 and 2012, 134 patients with CC, 152 with HGE and 160 with HGS were treated at two referral centers. Median follow-up was 11.5 years. Ten years RFI rates were 80.6%, 72.1%, 60.6%, and CSS rates were 84.3%, 82.6%, 81.7% respectively. Adjuvant chemotherapy significantly improved RFI (aHR 0.61, 95%CI 0.40 to 0.91, P = 0.015). In the multivariable analysis HGS histotype was associated with a shorter RFI compared to CC, (Hazard Ratio [HR]: 1.81; 95%CI: 1.12–2.93; P = 0.016), whereas CSS was not statistically different. prCSS was longer in HGS compared to CCOC (HR, 0.36; 95% CI, 0.17–0.74; P = 0.006).According to the stage, IA/IB/IC1 HGSOC had a shorter RFI (HR, 2.13; 95% CI, 1.14–3.99; P = 0.018) compared to IA/IB/IC1 CCOC, but similar CSS. For prCSS, CC compared to HGS conferred a worse prognosis regardless of the initial stage.ConclusionsEarly-stage CCOC is associated with a longer RFI, similar CSS and a shorter prCSS compared to HGSOC. No prognostic differences were observed between CC and HGE OC. The relapse risk was the lowest in IA/IB/IC1 CC compared to HGS, whereas CC displayed poor sensitivity to chemotherapy after relapse.     

A multicenter evaluation of adjuvant therapy in women with optimally resected stage IIIC endometrial cancer

ObjectiveTo determine if there is an advantage to combination chemotherapy and radiation for optimally resected stage IIIC endometrial cancer (EC).MethodsA multicenter retrospective analysis of patients with EC from 1991 to 2008 was conducted. Inclusion criteria were lymph node assessment and optimally resected disease. Recurrence-free (RFS) and overall survival (OS) were analyzed using Kaplan–Meier method and Cox proportional hazards model.Results265 patients with optimally resected stage IIIC EC were identified. Postoperative therapies included radiotherapy in 17% (n = 45), chemotherapy in 17% (n = 46), and both chemotherapy and radiation in 61% (n = 161). Three-year RFS was 56% for chemotherapy alone, compared to 73% for radiation alone, and 73% for combination therapy (p = 0.12). Those receiving chemotherapy alone had the worst 3-year OS (78%) compared to either radiotherapy alone (95%) or combination therapy (90%) (p = 0.005). After adjustment for stage and grade those treated with chemotherapy alone were at a 2.2 fold increased risk of recurrence (95% CI, 1.2 to 4.2; p = 0.02) and 4.0 fold increased risk of death (95% CI, 1.6 to 10.0; p = 0.004) compared to those treated with chemotherapy and radiation. In contrast there was no significant difference in RFS [HR = 1.0 (95% CI, 0.5 to 2.0; p = 0.92)] or OS [HR = 1.1 (95% CI, 0.3 to 3.6; p = 0.91)] for those treated with radiation alone compared to those treated with chemotherapy and radiation.ConclusionAdjuvant therapy with either radiation alone or chemotherapy and radiation was associated with improved outcomes for patients with optimally resected stage IIIC EC compared to those treated with chemotherapy only.     

The prognostic significance of preoperative leukocytosis in epithelial ovarian carcinoma: A retrospective cohort study

Objective

Preoperative leukocytosis is known to be a negative prognostic factor for several gynecologic malignancies, but its relationship with epithelial ovarian carcinoma (EOC) is unknown. We sought to evaluate the prognostic implications of preoperative leukocytosis for women with EOC.

Methods

We retrospectively reviewed the medical records of patients who underwent primary debulking surgery and adjuvant platinum-based chemotherapy for EOC between January 1993 and October 2011. Associations between leukocytosis and recurrence-free survival (RFS) and overall survival (OS) were determined by univariate analyses. Multivariate Cox proportional hazards regression was used to identify independent prognostic factors for RFS and OS.

Results

Of 155 women, 23 (14.8%) had leukocytosis and 132 (85.2%) did not have leukocytosis. RFS and OS were significantly shorter for women with leukocytosis than for women without leukocytosis (P = 0.009 and P < 0.0001, respectively). The mortality rate was also higher among women with leukocytosis (P < 0.0001). Multivariate analysis revealed that preoperative leukocytosis (hazard ratio [HR]: 2.15; 95% confidence interval [CI]: 1.55–4.41; P = 0.009), advanced stage (HR: 3.12; 95% CI: 1.44–6.75; P = 0.004), and optimal cytoreduction (HR: 0.38; 95% CI: 0.14-0.70; P = 0.031) were independent prognostic factors for RFS. Additionally, preoperative leukocytosis was independently associated with decreased OS (HR: 7.66; 95% CI: 2.78–21.16; P < 0.0001).

Conclusions

Among women with EOC, preoperative leukocytosis might be an independent prognostic factor for RFS and OS. A larger-scaled, prospective study is needed to verify these results.     

Perinatal and obstetric outcomes in singleton pregnancies following fresh versus cryopreserved blastocyst transfer: a meta-analysis

The transfer of cryopreserved blastocysts is increasing in IVF centres. However, little is known about the perinatal and obstetric outcomes of this procedure. In an attempt to further elucidate these issues, a systematic review and meta-analysis was conducted to compare cryopreserved transfer with fresh blastocyst embryo transfer. The results show that the risk of both preterm (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80–0.99, P = 0.04) and low birthweight births (OR 0.82, 95% CI 0.68–0.99, P = 0.04) was significantly lower after cryopreserved blastocyst transfer than after fresh blastocyst transfer. The rate of large for gestational age births was significantly higher (OR 1.68, 95% CI 1.55–1.82, P < 0.00001) and the rate of small for gestational age births significantly lower (OR 0.59, 95% CI 0.54–0.65, P < 0.00001) after cryopreserved blastocyst transfer. The transfer of cryopreserved blastocysts was associated with a significantly lower risk of placental abruption (OR 0.58, 95% CI 0.40–0.83, P = 0.003) but a significantly higher risk of Caesarean section (OR 1.21, 95% CI 1.01–1.43, P = 0.03). In conclusion, the perinatal and obstetric outcomes associated with the transfer of cryopreserved blastocysts differ from those associated with fresh blastocyst transfer.     

Naples prognostic score is an independent prognostic factor in patients with operable endometrial cancer: Results from a retrospective cohort study

ObjectiveNaples prognosis score (NPS) is a new immune and nutritional assessment method that can be used to predict tumor prognosis. This study aimed to identify whether NPS is an independent prognostic indicator of operable endometrial cancer (EC).Materials and methodsWe retrospectively analyzed 1038 patients with endometrial cancer who underwent surgery. Patients were grouped according to NPS (NPS group 0, n = 362; NPS group 1, n = 589; and NPS group 2, n = 87), and differences in clinical characteristics were compared among the groups. Survival analysis was performed by the Kaplan–Meier method, P values were calculated by log–rank test, and prognostic factors were assessed by Cox proportional hazards regression models.ResultsSerum albumin levels, total cholesterol levels, neutrophil–lymphocyte ratio, lymphocyte–monocyte ratio, total lymphocyte count, CA-125 levels, age, body mass index, FIGO stage, myometrial invasion depth, controlling nutritional status score, and systemic inflammation score were significantly different among the groups; significant differences in progression-free survival(PFS) and overall survival (OS) were also found. On multivariate analysis, NPS was identified as an independent prognostic factor for PFS (NPS group 0 vs. 1: aHR = 4.32, 95%CI = 1.133–16.47; NPS group 0 vs. 2: aHR = 21.336, 95%CI = 3.498–130.121) and OS (NPS group 0 vs. 1: aHR = 5.029, 95%CI = 1.638–15.441; NPS group 0 vs. 2: aHR = 20.789, 95%CI = 4.381–98.664). Moreover, NPS is an independent prognostic factor for PFS and OS in grade 2 or 3 EC (aHR = 7.768, 95%CI = 2.411–25.029 and aHR = 4.717, 95%CI = 1.794–12.407, respectively).ConclusionHigh NPS is associated with poor PFS and OS and is a valuable independent prognostic factor in patients with EC.     

Comparison of adjuvant chemoradiotherapy versus radiotherapy in early-stage cervical cancer patients with intermediate-risk factors: A systematic review and meta-analysis

The presence of intermediate risk factors reduces the predictability of radical hysterectomy, demanding the use of adjuvant therapy for treatment of Early stage cervical cancer (ESCC) patients. Adjuvant radiotherapy (RT) and chemoradiotherapy (CRT) has been widely used with varied efficacy and safety issues. Therefore, the aim of this systematic review and meta-analysis was to update the available evidence and assess the effect of post-surgical adjuvant RT versus adjuvant CRT on survival rate and complications/toxicities in management of ESCC patients with intermediate risk factors. PubMed, EMBASE and Web of Science (WOS) and CENTRAL were searched using a combination of relevant keywords. All studies comparing outcomes of adjuvant RT versus CRT in ESCC patients with intermediate-risk factors in terms of recurrence free survival (RFS), overall survival (OS) and toxicities/complications were included. Both qualitative and quantitative analysis was carried out. The risk of bias assessment was done using Newcastle–Ottawa scale (NOS) for retrospective cohort studies and Cochrane risk of bias assessment tool was used for randomized clinical trials. Eleven retrospective cohort studies and two randomized clinical trials were included in this review. Adjuvant CRT was found to have better RFS with ESCC patients with multiple intermediate risk factors with OR 3.11 95% CI [1.04, 4.99], p < 0.0001; i2 = 6%. However, similar benefit was observed between both regimens in presence of a single intermediate risk factor OR 1.80 95% CI [0.96, 3.36], p = 0.07; i2 = 0%. Grade 3 or 4 haematological toxicity among patients receiving post-surgical adjuvant RT versus adjuvant CRT showed increased association of toxicity with adjuvant CRT with OR 7.73 95%CI [3.40, 17.59], p < 0.0001; i2 = 62%. Adjuvant CRT shows favourable RFS and OS in ESCC patients with multiple intermediate risk factors. CRT also showed greater incidence of grade 3 or 4 haematological and non-haematiological toxicity, however, the same could be well tolerated when used within the recommended dosage.     

Effect of oral magnesium supplementation for relieving leg cramps during pregnancy: A meta-analysis of randomized controlled trials

Leg cramps are one of the common symptoms during pregnancy. About 30%–50% of pregnant women experience leg cramps twice a week. Leg cramps may cause severe pain and sleep disturbance, hinder performance of daily activities and may lengthen the duration of pregnancy and the type of childbirth. Several randomized controlled trial (RCT) studies focused on the effects of the magnesium supplement for relieving leg cramps. However, the results were inconsistent. Five databases were searched from their inception to July 2, 2020. We summarized the weighted mean difference (WMD) with 95% CIs for “the frequency of leg cramps after treatment”, and summarized the odds ratio (OR) with 95% confidence intervals (CIs) for “recovery from leg cramps” and “side effects”. Four RCTs with a total of 332 pregnant women were identified. The frequency of leg cramps after treatment was not decreased in the treatment group compared to the control group (WMD = ?0.47, 95% CI: ?1.14–0.20, P = 0.167). Magnesium supplementation cannot improve the recovery from leg cramps compared to the control group (OR = 0.47, 95% CI: 0.14–1.52, P = 0.207). Magnesium supplementation had no significant side effects in the treatment group compared to the control group (OR = 1.82, 95% CI: 0.90–3.69, P = 0.094). Oral magnesium supplementation is not effective in the treatment of leg cramps during pregnancy.ProsperoCRD42020196572.     

Value of serum procalcitonin as an early predictor of antibiotic treatment response in inpatients with pelvic inflammatory disease (VALID)

ObjectiveThis study aimed to investigate the value of serum procalcitonin as an early predictor of antibiotic treatment response in the inpatient management of pelvic inflammatory disease (PID).Materials and methodsA prospective observational study was carried out at a university hospital. Patients admitted for pelvic inflammatory disease were classified into 2 groups: responders and non-responders. The primary outcome measure was the serum level of procalcitonin at the time of admission. The secondary outcome measures were other serum inflammatory markers including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell (WBC) count.ResultsBaseline characteristics were similar between the groups. Serum level of procalcitonin at the time of admission did not differ between the groups (P = 0.564). However, the non-responders had more elevated CRP and ESR compared to the responders (P = 0.045 and P = 0.030, respectively). CRP showed the highest accuracy of 72.1% (95% confidence interval [CI], 59.2 to 82.9) in predicting antibiotics response, while procalcitonin showed the lowest accuracy of 49.1% (95% CI, 35.1 to 63.2).ConclusionCompared with standard inflammatory markers such as CRP or ESR, procalcitonin had limited diagnostic value in predicting antibiotics response in patients admitted for PID. Therefore, procalcitonin measurement cannot be recommended as a laboratory test for patients with PID and the value of its routine use remains inconclusive.     

The impact of tumor fragmentation in patients with stage I uterine leiomyosarcoma on patterns of recurrence and oncologic outcome

ObjectiveTo evaluate the impact of tumor fragmentation on oncologic outcomes in patients with stage I uterine leiomyosarcoma (uLMS).MethodsWe identified all patients diagnosed with stage I uLMS presenting to our institution within three months of primary surgery, 1/2000–1/2019. Patients with recurrent disease were excluded. The non-morcellated group had total hysterectomy without documented specimen fragmentation; the morcellated group, total hysterectomy with documented specimen fragmentation. We defined fragmentation as manual fragmentation or morcellation (via power morcellator or otherwise) of the specimen in peritoneal cavity or vagina. Appropriate statistical analyses were performed.Results152 patients met inclusion criteria. 107 (70%) underwent total hysterectomy (non-morcellated); 45 (30%) underwent morcellation. Median age at diagnosis for the entire cohort was 55 years (range 30–91). Median follow-up was 42.1 months (range 1.1–197.8). 40 (26.3%) patients had primary surgery at our institution, 112 (73.7%) at an outside hospital. In total 110 (72.3%) recurred: 72/107 (67.2%) non-morcellated; 38/44 (86.3%) morcellated. Median progression-free survival (PFS) for non-morcellated versus morcellated was 13.8 (95%CI 9.2–20.2) versus 7.3 months (95%CI 3–13.1), HR 1.5 (95%CI 1.02–2.24); P = 0.04. Median overall survival (OS) for non-morcellated versus morcellated was 82.1 (95%CI 52.4–122) versus 47.8 months (95%CI 28.5–129.6), HR 1.1 (95%CI 0.67–1.82); P = 0.7. Among patients with recurrence, 69.4% of non-morcellated recurred at hematogenous sites only, 18.1% recurred in peritoneum only; 28.9% of morcellated recurred at hematogenous sites, 63.2% in peritoneum. Race, lymphovascular invasion, postoperative chemotherapy, were independently associated with PFS. Mitotic index was independently associated with OS.ConclusionsTumor fragmentation/morcellation was associated with significantly higher risk of recurrence and a nearly 4-fold increase in peritoneal recurrence. Prognostic biomarkers remain important in predicting oncologic outcomes, independent of fragmentation or treatment.     

Societal awareness on neonatal hyperbilirubinemia: A systematic review and meta-analysis

Early recognition of neonatal hyperbilirubinemia is essential for prevention of bilirubin neurotoxicity and its long-term sequelae. High rates of home delivery in low- and middle-income countries (LMICs) as well as early discharge post-delivery (within 24hours) make community surveillance for neonatal hyperbilirubinemia highly important. Here, we performed a literature review to estimate the level of societal awareness of neonatal hyperbilirubinemia. We searched several databases for studies assessing the knowledge and awareness of neonatal hyperbilirubinemia. We retrieved 211 citations from 206 databases with five being in the grey literature. 52 selected articles were further reviewed. Data from these studies were then analyzed using Stata software (Statacorp® LLC Texas USA). We found that the pooled estimate of societal awareness of neonatal hyperbilirubinemia was 67% (95% confidence interval [CI]: 60, 74). There however was a publication bias (Begg test: P ≤ 0.01; Egger P = 0.06). Studies that scored or graded knowledge reported lower estimates [adjusted odds ratio (aOR) = -0.17; 95% CI: -0.32–0.02; P = 0.03]. Hospital location was an important determinant of awareness of complications [aOR = 0.30; 95% CI: 0.30–0.57; P = 0.03]. We therefore concluded that there is a significant need to improve societal awareness of neonatal hyperbilirubinemia.     

Impact of Third-Trimester Measurement of Low Uterine Segment Thickness and Estimated Fetal Weight on Perinatal Morbidity in Women With Prior Cesarean Delivery

ObjectivesThis study aimed to estimate the impact of third-trimester ultrasound with measurement of the lower uterine segment thickness (LUST) and estimation of fetal weight (EFW) on maternal and perinatal morbidity among women with a prior cesarean delivery.MethodsWe performed a secondary analysis of the QUARISMA trial, including women who delivered at term after one prior cesarean delivery in tertiary care centres. Major and minor maternal and perinatal morbidities were compared between centres that had introduced LUST and EFW measurements into routine practice and those that had not, using generalised estimating equations and adjusted odds ratios (aOR). In a secondary analysis, we compared women who underwent a trial of labour with and without LUST and EFW measurements.ResultsWe observed a significant reduction in major perinatal morbidity (aOR 0.52; 95% CI 0.28–0.96, P = 0.04), minor perinatal morbidity (aOR 0.49; 95% CI 0.25–0.96, P = 0.04), and minor maternal morbidity (aOR 0.56; 95% CI 0.34– 0.94, P = 0.03) but no significant difference in major maternal morbidity (aOR 0.40; 95% CI 0.04–3.69, P = 0.42) in the 2 centres that had introduced third-trimester ultrasound with EFW and LUST measurements (1458 women), compared with the 4 centres (1247 women) that had not. Among women who underwent a trial of labour, we observed a reduction in major perinatal morbidity (aOR 0.25; 95% CI 0.11–0.54, P < 0.001) and a lower rate of uterine rupture (0% vs. 0.3%, P = 0.045) with LUST and EFW measurements.ConclusionThird-trimester ultrasound with EFW and LUST measurement is associated with a significant reduction in major perinatal morbidity in women with a prior cesarean delivery.     

Parenchymal splenic metastasis is an independent negative predictor of overall survival in advanced ovarian,fallopian tube,and primary peritoneal cancer

ObjectiveThe purpose of this study was to evaluate the significance of parenchymal splenic metastasis (PSM) in ovarian (OC), fallopian tube (FTC), and primary peritoneal cancer (PPC).MethodsAll patients with stage IIIB–IV OC, FTC, and PPC undergoing primary cytoreduction from 2001 to 2010 at our institution were identified. In patients undergoing splenectomy, pathology was reviewed for the presence of PSM. Multivariate Cox regression and Kaplan–Meier survival analysis were used to evaluate factors associated with overall survival (OS).ResultsOf 576 patients identified, stage was: IIIB — 23 (4%), IIIC — 468 (81.2%), and IV — 85 (14.8%). Optimal cytoreduction was achieved in 430 patients (74.7%), including 85 of 97 patients (87.6%) undergoing splenectomy. PSM was identified in 20 patients (20.6%) undergoing splenectomy, including 3 of 5 patients (60%) with radiographically identified parenchymal liver metastases and 17 of 92 patients (18.5%) without such radiographic findings (P = 0.059). Age, preoperative albumin, residual disease, stage, bulky upper abdominal disease, IP chemotherapy, and PSM were associated with OS on univariate analysis. Splenectomy was not associated with survival. Age, preoperative albumin, residual disease, stage, and PSM (HR = 0.46; 95% CI, 0.27–0.77) were associated with OS on multivariate analysis. In the subset of patients undergoing splenectomy, OS was lower for patients with PSM versus those without PSM (28.5 v 51.2 months, P = 0.004).ConclusionsPSM is independently associated with decreased OS in patients with advanced OC, FTC, and PPC. PSM occurs in the setting of other evidence of hematogenously disseminated disease, but also occurs outside this setting. PSM should be considered a criterion for stage IV disease.     

The importance of chemotherapy and radiation in uterine papillary serous carcinoma

Purpose

To identify prognostic and predictive factors of overall survival (OS), relapse-free survival (RFS) and toxicity for patients with uterine papillary serous carcinoma (UPSC).

Materials and methods

Patient, tumor, treatment and relapse characteristics of 135 women with Stages I-IVA UPSC treated between 1980 and 2006 at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) were analyzed using Cox regression models to determine prognostic and predictive factors for OS, RFS and toxicity.

Results

Mean follow-up was 5.5 years (range, 0.01-25.2). Median 5-year OS was 52%, and RFS was 42% for all patients. On Cox regression analysis, increasing age, stage, and myometrial invasion were prognostic factors associated with shorter OS and RFS. A paclitaxel-platinum chemotherapy regimen was significantly associated with longer OS (hazard ratio [HR] = 0.34, 95% confidence interval [CI] 0.15-0.74, p = 0.007) and RFS (HR = 0.45, 95% CI 0.22-0.92, p = 0.03). RFS was improved for patients treated with RT (HR = 0.44, 95% CI 0.25-0.77, p = 0.004). The 5-year grade 3+ toxicity rate was 3.5% for those who received RT and was 2.9% for those who did not (p = NS).

Conclusion

Uterine papillary serous cancer can be an aggressive tumor type with a poor prognosis. RFS was improved by radiation and chemotherapy with few grade 3 or higher complications. Using radiation and paclitaxel-platinum chemotherapy should be attempted whenever feasible for patients with UPSC who do not have distant metastases at diagnosis.     

Oncological Safety of Laparoscopic Surgery for Women with Apparent Early-stage Uterine Clear Cell Carcinoma: A Multicenter Retrospective Cohort Study

Study ObjectiveTo study the effect of different surgical approaches (laparoscopy and laparotomy) on the oncological outcomes of patients with apparent early-stage uterine clear cell carcinoma (UCCC).DesignRetrospective cohort study.SettingFour Chinese teaching hospitals.PatientsA total of 273 women with apparent early-stage UCCC.InterventionsAll included patients were surgically staged by laparoscopy or laparotomy.Measurements and Main ResultsThe eligible patients were divided into the laparotomy group and the laparoscopy group. Disease-free survival (DFS) and overall survival (OS) were evaluated by the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazards regression model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the effect of surgical approach on DFS and OS.With a median follow-up of 31.0 months, the 3-year DFS rates were 68.82% and 64.27% in the laparotomy group and the laparoscopy group, respectively. The difference in DFS between the 2 groups was not statistically significant (HR, 1.06; 95% CI, 0.72–1.58; p = .758). In addition, the 3-year OS rate (72.76% vs 73.46%; HR, 1.06; 95% CI, 0.65–1.72; p = .823) was not different between the 2 groups. Furthermore, multivariable analysis showed that for patients with apparent early-stage UCCC, the approach of surgical staging was not an independent prognostic factor for OS (adjusted HR, 1.29; 95% CI, 0.78–2.12; p = .321) and DFS (adjusted HR, 1.11; 95% CI, 0.73–1.68; p = .621).ConclusionFor clinical early-stage clear cell carcinoma of the uterus, staging by laparoscopy is oncologically safe. This needs to be justified by further prospective studies.     

Obstetric Perineal Tears in Pregnant Adolescents and the Influencing Factors

Study ObjectiveThe incidence and risk factors of obstetric perineal tear occurrence in vaginal delivery of adolescent pregnant patients are not well established. We aimed to describe the incidence of obstetric perineal tears in adolescents and the maternal obstetric risk factors associated with this situation.DesignRetrospective cohort studySettingDepartment of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, TurkeyParticipantsAdolescent pregnant patients (≤19 years) who delivered vaginally in our institution between January 2014 and January 2021Interventions and Main Outcome MeasuresThe main outcome measures were the incidence of perineal tears, the degree of perineal tears, and the risk factors associated with severe perineal tears in adolescents. Severe perineal tears include third- and fourth-degree lacerations. A third-degree tear is defined as partial or complete disruption of the anal sphincter muscles, and a fourth-degree tear is defined as lacerations involving the rectal mucosa.ResultsA total of 3441 adolescents who had a vaginal delivery were included in the study. The rate of severe perineal tear was 5.8% (200/3441). Risk factors associated with obstetric laceration in adolescents in multivariate analysis were nulliparity (OR = 1.72; 95% CI, 1.14–2.41; P = 0.007), high birth weight (OR = 4.1; 95% CI, 2.71–6.21; P < 0.001), and labor induction (OR = 1.36; 95% CI, 1.01–1.85; P = 0.02). Spontaneous onset of labor and previous delivery reduced the risk of severe perineal tear in adolescent pregnant patients (respectively, OR = 0.68; 95% CI, 0.51–0.94; P = 0.02 and OR = 0.51; 95% CI, 0.33–0.79; P = 0.007).ConclusionsIn adolescents, the risk of severe perineal tear was associated with nulliparity, birth weight, and labor induction. The only possible modifiable risk factor was labor induction.     

Factors affecting clinical outcomes in women with non-gastric gastrointestinal stromal tumors

ObjectiveThe clinical presentation of non-gastric GISTs might mimic adnexal cancer, and non-gastric GIST might be managed and treated by gynecologists. Knowledge of the clinical outcomes of women with non-gastric gastrointestinal stromal tumors (GISTs) is important. Our aim is to elucidate the factors affecting the clinical outcomes of women with non-gastric GISTs.Materials and methodsBetween January 2000 and October 2019, all consecutive women with non-gastric GISTs who underwent surgery in a tertiary referral center were reviewed.ResultsTwenty-six women were reviewed. Eight (31%) women experienced recurrence. The probabilities of recurrence-free survival (RFS) at 60 and 120 months were 65.2% and 55.9%, respectively. The probabilities of overall survival (OS) at 60 and 120 months were 71.1% and 63.9%, respectively. Cancer stage was the only independent predictor of RFS (hazard ratio = 6.00, p = 0.007) and OS (hazard ratio = 3.88, p = 0.04). However, excluding cancer stage, metastasis (hazard ratio = 8.74) was the only independent predictor of RFS, and tumor size (hazard ratio = 1.20) and metastasis (hazard ratio = 6.03) were independent predictors of OS. Tumor size ≥13.9 cm was the optimum cut-off value to predict death and had an area under the receiver operating characteristic curve of 0.75 (95% confidence interval = 0.53 to 0.98). Among the above 5 women with non-gastric GISTs admitted to the Gynecology Department, optimal debulking surgery was performed in two women, and small bowel resection was performed in three women; and all five women remained alive without disease.ConclusionNon-gastric GISTs may mimic gynecologic tumors. Metastasis was an independent predictor of PFS. In addition, metastasis and large tumor size (especially ≥13.9 cm) were independent predictors of OS in women with non-gastric GISTs.