Optimizing the treatment of ovarian cancer: Neoadjuvant chemotherapy and interval debulking versus primary debulking surgery for epithelial ovarian cancers likely to have suboptimal resection

Objective

To: a) identify prognostic factors in patients with epithelial ovarian cancer treated with neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS), and b) compare post-surgical survival between patients treated with NACT/IDS for presumed unresectable disease and stage IIIC/IV patients who underwent suboptimal primary debulking surgery (PDS).

CA125 kinetic parameters predict optimal cytoreduction in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy

ObjectiveTo evaluate the different kinetic parameters of serum CA125 during neoadjuvant chemotherapy (NAC) to predict optimal interval debulking surgery (IDS).MethodsThe present retrospective multicenter study included patients with advanced ovarian cancer treated with neoadjuvant platinum-based chemotherapy followed by IDS between 2002 and 2009. Demographic data, CA125 levels, radiographic data, chemotherapy and surgical-pathologic information were obtained. Univariate and multivariate analyses were performed to evaluate variables associated with complete IDS. ROC analysis was used to determine potential cut-off values to predict the likelihood of complete cytoreduction via IDS.ResultsOne hundred and forty-eight patients met the study criteria. Ninety-three patients (62.8%) had optimal cytoreduction with no residual macroscopic disease (CC-0) after IDS. In multivariate analyses, the CA125 level after the 3rd NAC was an independent predictor for optimal cytoreduction (odds ratio: 0.98 [0.97–0.99], p = 0.04). The area under the ROC curve was 0.73. A threshold of 75 UI/ml displayed the most predictive power. The odds ratio to predict complete cytoreduction was 3.29 [1.56–7.10] (p = 0.0008).ConclusionOur data indicate that for advanced ovarian cancer, a CA125 level less than 75 UI/ml after the 3rd NAC was an independent predictor factor for complete IDS.     

Intraperitoneal Chemotherapy for Advanced Ovarian and Peritoneal Cancers in Patients Following Interval Debulking Surgery or Primary Cytoreductive Surgery: Tom Baker Cancer Centre Experience From 2006 to 2009

ObjectiveTo describe our experience with cisplatin- and paclitaxel-based IP chemotherapy in patients treated initially with either neoadjuvant chemotherapy and interval debulking surgery (IDS) or primary cytoreductive surgery (PCRS).MethodsWe performed a retrospective review of the records of 67 patients (38 IDS, 29 PCRS) enrolled in the intraperitoneal (IP) chemotherapy program at the Tom Baker Cancer Centre between 2006 and 2009. Information pertaining to patient demographics, IP chemotherapy toxicity, and catheter complications was extracted, and the median time to recurrence was calculated.ResultsMost patients in the study were aged 50 to 70 years and had a diagnosis of stage III serous ovarian cancer. Overall, 295/393 IP cycles (75%) were successfully administered. The proportion of patients completing six cycles of chemotherapy in the IDS and PCRS groups was 53% and 59%, respectively. Frequent (> 25%) Grade 1 to 2 chemotherapy toxicities included fatigue, peripheral neuropathy, and nausea. Catheter complications were observed in 34% of patients (23/67). The recurrence rates for patients completing four or more cycles of IP chemotherapy in the IDS and PCRS groups were 58% and 35%, respectively, with the median time to recurrence approximately one year.ConclusionAlthough IP chemotherapy is well tolerated in both IDS and PCRS patients, the median time to recurrence is shorter than expected.     

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.     

Influence de l’indice de masse corporelle sur la prise en charge et le pronostic des patientes avec carcinome endométrial

ObjectiveThe aim of this study was to evaluate the outcome of surgery, postoperative morbidity and prognosis of patients with endometrial cancer in function of the body mass index (BMI).Patients and methodsThe study cohort consisted of consecutive women undergoing surgery for endometrial cancer in our institution between January 2000, and September 2012. Individual records of all patients were reviewed and analyzed. Patient BMI was categorized as underweight, normal, overweight and obese.ResultsA total of 192 patients were evaluated. Patients were followed for one to 153 months with a mean of 52.56 months. The mean BMI and the range of each of the BMI categories were 16.97 kg/m² (14–18), 22.97 kg/m² (20–24.9), 27.61 kg/m² (25.7–29.4), 37.34 kg/m² (30–71). Women with higher BMI were more frequently affected by hypertension (8.3%, 31.43%, 58.13% and 59.7% respectively, P < 0.0001) and diabetes (16.67%, 4.3%, 13.9% and 29.85% respectively, P = 0.02). Women with normal BMI had more frequently postmenopausal replacement therapy than the other categories (P = 0.0004). Surgical operative time, mean length of hospitalization in days were not significantly different among the 4 groups. In the obese group there were significantly higher peroperative blood loss (P = 0.01), more wound abces (P = 0.05), more eventration (P = 0.02) and more reinterventions for complications (P = 0.03). Patients had the same protocols of treatment (surgery and adjuvant treatment) and histological characteristics were the same between groups but obese patients had much less positive lymph nodes (P = 0.03). There were no statistically significant difference in overall 5-years survival between groups (P = 0.54)Discussion and conclusionsOur study demonstrate a survival equivalency for obese and non-obese women even though obese women showed less positive lymph nodes.     

Paclitaxel,epirubicin, and cisplatin (TEP) regimen as neoadjuvant treatment in locally advanced cervical cancer: Long-term results

ObjectiveWe evaluated the rates of response, operability and long term survival and toxicities in a large series of locally advanced cervical cancer (LACC) patients administered neoadjuvant chemotherapy (NACT) with paclitaxel, epirubicin and cisplatin (TEP) followed by radical surgery (RS).Patients and methodsThe study included 75 consecutive stages IB2–IVA patients administered NACT with paclitaxel (175 mg/m²), epirubicin (100 mg/m²) and cisplatin (100 mg/m²) on day 1 of a 3-weekly cycle for 2–4 cycles. Patients were evaluated for objective response by RECIST criteria and triaged to RS. Progression-free survival (PFS) and overall survival (OS) were calculated from the date of diagnosis to recurrence/progression of disease or death, respectively.ResultsComplete and partial clinical response was observed in 13 and 28 patients (56.1% objective responses); radical surgery was amenable in 52 patients (71.2%): 14 patients showed complete/microscopic response to treatment. Overall, recurrence/progression of disease was observed in 36 patients, and all of them experienced death of disease. In the whole series median PFS was 48 months (5-year PFS = 51.0%), and median OS was 72 months (5-year OS = 53.0%). Overall, 195 courses were administered; treatment was delayed in 6.7% of patients, while dose reduction was required in 36.5% of patients. Grade 3 leukopenia affected 22 patients (29.7%), while Grades 3 and 4 neutropenia was documented in 17 (22.9%) and 6 (8.1%) patients. In the whole series, we recorded 1 death whose relation with treatment-induced toxicity could not be ruled out.ConclusionsTEP provided favorable rates of response and operability in LACC patients, and allowed the obtainment of encouraging survival data without carrying out an excessive toxicity.     

Is Obesity a Further Cardiovascular Risk Factor in Patients with Erectile Dysfunction?

IntroductionErectile dysfunction (ED) and, in particular, arteriogenic ED have been proposed as new markers of risk for incident major adverse cardiovascular events (MACE). Reduced penile blood flow is more common in obese people than in leaner ED subjects.AimTo explore the interaction of overweight/obesity and penile blood flow in the prediction of incident MACE.MethodsThis is an observational prospective cohort study evaluating a consecutive series of 1,687 patients attending our andrological unit for ED. Different clinical, biochemical, and instrumental (penile flow at color Doppler ultrasound: PCDU) parameters were evaluated.Main Outcomes MeasuresAccording to body mass index (BMI), subjects were divided into three groups: normal weight (BMI = 18.5–24.9 kg/m²), overweight (BMI = 25.0–29.9 kg/m²), and obese (BMI ≥ 30.0 kg/m²). Information on MACE was obtained through the City of Florence Registry Office.ResultsAmong patients studied, 39.8% were normal weight, while 44.1% and 16.1% showed BMI 25–29.9 and 30 kg/m² or higher, respectively. During a mean follow-up of 4.3 ± 2.6 years, 139 MACE, 15 of which were fatal, were observed. Cox regression model, after adjusting for age and Chronic Diseases Score, showed that obesity classes along with the presence of arteriogenic ED (peak systolic velocity at PCDU <25 cm/second) were significantly and independently associated with incident MACE (hazard ratio = 1.47 [1.1–1.95], P < 0.05 and 2.58 [1.28–5.09], P < 0.001, respectively). When a separate analysis was performed for classes of obesity, reduced peak systolic velocity at PCDU (<25 cm/second) was significantly associated with incident MACE in obese (BMI ≥ 30 kg/m²), but not in leaner, subjects.ConclusionsIn obese subjects, more than in leaner ED subjects, impaired penile blood flow is associated with an increased risk of incident cardiovascular disease. The interaction with concomitant risk factors, such as obesity, should be taken into account when assessing the predictive value of penile blood flow for cardiovascular diseases. Corona G, Monami M, Boddi V, Balzi D, Melani C, Federico N, Balzi D, Sforza A, Rotella CM, Forti G, Mannucci E, and Maggi M. Is obesity a further cardiovascular risk factor in patients with erectile dysfunction?     

Clinical outcome of neoadjuvant chemotherapy for advanced ovarian cancer

Objective

To evaluate clinical outcome in patients selected to receive neoadjuvant chemotherapy (NACT) compared to primary debulking surgery (PDS).

Preoperative HE4 expression in plasma predicts surgical outcome in primary ovarian cancer patients: Results from the OVCAD study

ObjectivesEpithelial ovarian cancer (EOC) is the major cause of death due to gynecological malignancies. The most important prognostic factors are residual tumor mass after surgery and platinum-response. No predictive biomarkers are available to identify patients who will benefit from standard treatment. The aim of our study was to analyze the role of HE4 in predicting surgical and clinical outcome in primary EOC.MethodsIn the European multicentric project “OVCAD”, 275 consecutive patients with primary EOC were enrolled. Patients were eligible if radical cytoreductive surgery was performed and platinum-based chemotherapy was applied. Plasma and ascites samples were collected before or during surgery. The concentrations of HE4 and CA125 was determined using ELISA and Luminex technique, respectively.ResultsMedian age at first diagnosis was 58 years (range 18–85 years). Most patients presented with advanced stage disease, FIGO III or IV (94.6%), grades II–III (96%) and serous histology (86.2%). In most cases a complete cytoreduction to no residual tumor mass was achieved (68.4%). Higher plasma HE4 levels correlated with poor surgery outcome in terms of macroscopically residual tumor mass (p < 0.001) and platinum-resistance (p = 0.009). Plasma CA125 and the risk index (HE4 and CA125) were independent predictive factors for surgical outcome (p = 0.001, OR = 3.37, 95% CI = 1.61–7.06 and p < 0.001, OR = 6,041, 95% CI = 2.33–15.65, respectively). FIGO stage III was an independent predictive factor for platinum response (p = 0.039, OR = 0.436, 95% CI = 0.198–0.960).ConclusionsThe presented data are showing that the combination of HE4 and CA125 expression in plasma might predict the surgical outcome in EOC and by this may have a prognostic impact on PFS and OS.     

High-dose density neoadjuvant chemotherapy in bulky IB cervical cancer

ObjectiveThe endpoint of this prospective study is to evaluate response rate, survival and toxicity of high-dose density neoadjuvant chemotherapy (NAC) in bulky IB cervical cancer.Material and methodsBetween January 1998 and December 2009, 154 women were enrolled into study. Three patients were withdrawn. Of the 151 women, 119 had stage IB2 cervical cancer (78.8%) and 32 had stage IB1 cancer (21.2%) infiltrating the whole cervical stroma. Women received 3–4 cycle cisplatin-75 mg/m² and ifosfamide-2 g/m² in cases of squamous-cell cancer or cisplatin-75 mg/m² and doxorubicin-35 mg/m² in adenocarcinoma every 10 days and then underwent radical hysterectomy type III. Patients who had non-resectable disease underwent chemoradiotherapy.ResultsThe overall response rate (reduction of tumor volume more than 50%) was 78.8%. Reduction of tumor volume less than 50% was seen in 15.2%. Tumor progression during chemotherapy occurred in nine patients (6.0%). There were positive lymph-nodes in 26 patients (18.3%) of the 142 that underwent surgery. 38 women underwent adjuvant radiotherapy (26.7%). There were 26 recurrences (17.2%). After surgery 20 women recurred from 142 (14.1%) and after primary radiotherapy 6 from 9 women recurred (66.7%). 25 of 151 women died from disease (16.5%). At the time of the study, surgery was performed in 118 women 5 or more years ago, 19 of them died of disease. Five-year specific survival is 83.6%. Grade 3–4 neutropenia was found in only 7.3% of the women, and grade 3–4 thrombocytopenia were found in 1.3%.ConclusionHigh-dose density NAC appears to be feasible in the treatment IB bulky cervical cancer and toxicity is acceptable. Adjuvant radiotherapy was used only in 26.7%.     

Ovarian cancer patients with localized relapse: Clinical outcome and prognostic factors

ObjectiveWe evaluated the clinical outcome and prognostic factors for post-relapse survival (PRS) in a large retrospective series of ovarian cancer patients with localized relapse.Patients and methodsThe following radiological inclusion criteria were adopted: relapse in single anatomic site and ≤ 3 nodules. All cases were followed for at least 24 months after recurrent disease.ResultsTwo hundred twenty ovarian cancer patients met the inclusion criteria. Serous histotype and G3 tumors were observed in 173 (78.6%) and 151 (77.4%) cases, respectively. All women received platinum-based first-line chemotherapy. Overall, the median follow-up was 46 (8–249) months, and platinum-resistant relapse was documented in 51 women (23.2%). Eighty-one patients (36.8%) recurred in the peritoneum (LPeR), 76 patients (34.5%) in the abdominal lymph nodes (LLNR), and 63 patients (28.7%) in parenchymal organs (LPaR); 142 patients (64.5%) recurred with a single nodule; and 78 patients (35.5%) recurred with 2–3 nodules. Secondary cytoreductive surgery (SCS) was attempted in 73 cases (33.2%), and complete debulking was achieved in all patients. On multivariate analysis, platinum-free interval (PFI, χ² = 13.457, p value = 0.001), complete SCS (median PRS, 69 months vs 25 months, p = 0.001), anatomic site of relapse (median PRS, 41 months in LPeRs, 63 months in LLNRs and 24 months in LPaRs, p = 0.001), and number of nodules (median PRS, 58 months in patients with one nodule, 24 months in patients with 2–3 nodules, p = 0.001) were identified as predictors of PRS.ConclusionsBeside the duration of PFI, the complete SCS, the anatomic site of relapse, and the number of nodules were independent prognostic factor for duration of PRS.     

Cardiac function at term in human pregnancy

ObjectivesWe have previously demonstrated deterioration in cardiac function at term in human pregnancy. To explore further, we investigated central arterial hemodynamics and association with maternal weight during gestation.Study designPrimiparous women (n = 32) were recruited in a tertiary referral obstetric hospital and a longitudinal cohort study with analyses at median 16 and 37 weeks gestation undertaken. Subgroups of normal body mass index, <25 kg/m², and overweight, ?25 kg/m², at 16 weeks were created.Main outcome measuresWe performed 2D speckle tracking echocardiography strain analysis and tonometric measures of central arterial pressures, waveforms and pulse wave velocity.ResultsA reduction in cardiac strain (2P = 0.002) from 16 to 37 weeks gestation was associated with increased systemic vascular resistance (2P = 0.008), reduced arterial compliance (2P = 0.004) and increased central arterial pressures (2P < 0.001) and augmentation index (2P = 0.001).ConclusionsBy 37 weeks, compared with values in earlier pregnancy, overweight women had higher systemic vascular resistance (2P < 0.05). Additionally, their central diastolic pressure was higher (2P < 0.05) and their ventricular strain was lower (2P < 0.05) than in normal weight pregnant women. An increase in systemic vascular resistance and central arterial pressures by term may contribute to the observed deterioration in cardiac function. This appears more prominent in overweight women.     

The Impact of Maternal Body Mass Index on In Vitro Fertilization Outcomes

ObjectiveTo examine the effect of body mass index on gonadotropin dose requirements for ovarian stimulation, as well as other clinical outcomes in women undergoing in vitro fertilization.MethodsWe performed a retrospective cohort study involving 752 women undergoing a total of 951 IVF or IVF-ICSI cycles at a private fertility clinic between January 2007 and May 2011. The 951 treatment cycles were divided into three groups according to the weight of the women involved: normal weight (BMI < 25 kg/m², 461 cycles), overweight (25 ≤ BMI < 30 kg/m², 277 cycles), and obese (BMI ≥ 30 kg/m², 179 cycles). Total gonadotropin dose requirements and clinical IVF cycle outcomes (cycle cancellation, clinical pregnancy, and live birth) were compared between the three BMI groups. We performed multivariable analyses, adjusting for potential confounders such as age at cycle start, day 3 serum FSH level, smoking, presence of polycystic ovary syndrome, and duration of infertility.ResultsThere were no significant differences between the three BMI groups for any of the IVF cycle outcomes measured, including the total FSH dose required for ovarian stimulation. The likelihood of cycle cancellation, clinical pregnancy, and live birth were not significantly different between normal weight, overweight, and obese women.ConclusionObese women did not require significantly higher doses of gonadotropins for ovarian stimulation than normal weight individuals. At our centre, female obesity did not significantly affect the clinical outcomes of IVF treatment. However, given the conflicting results of existing studies, the effect of maternal obesity on IVF outcomes remains unclear.     

Effect of Obesity on Parameters of Ovarian Reserve in Premenopausal Women

ObjectiveTo study the relationship between obesity and serum and ultrasound markers of ovarian reserve in premenopausal women.MethodsWe performed a cross-sectional comparative study of two age-matched groups of premenopausal participants (early transition phase): 50 participants (“non-obese”) had a BMI < 30 kg/m², and the other 50 participants (“obese”) had a BMI of 30 to 35 kg/m². The obese women had a mean age of 46.2 years and the non-obese women had a mean age of 46.1 years. Blood samples were collected from all participants, anthropometric measurements were calculated, and transvaginal ultrasonography was performed to measure the antral follicle count (AFC) and ovarian volume during the early follicular phase. The blood samples were assayed for antimüllerian hormone (AMH), follicle-stimulating hormone (FSH), fasting blood glucose (FBG) and two-hour postprandial blood glucose (2 h PP).ResultsThere was no significant difference between the two groups in mean age, levels of serum AMH, serum FSH, FBG, 2 hr PP, or AFC. Ovarian volume was significantly lower in obese women (3.7 ± 0.8 mL) than in non-obese women (6.6 ± 0.4 mL) (P = 0.03). There was no significant correlation between BMI and serum AMH, serum FSH, FBS, or 2 hr PP.ConclusionObesity has no association with levels of serum FSH, AMH, blood glucose, or AFC indicating that obesity is unlikely to affect ovarian reserve in the perimenopausal age group.     

Grossesses interstitielles : traitement chirurgical,fertilité et devenir obstétrical. L’expérience rouennaise

ObjectivePresenting our experience concerning interstitial pregnancies (IP) surgical management and to evaluate our patients’ subsequent long-term fertility.Patients and methodTwenty patients underwent surgical treatment of IP in our department over 15 years. In this retrospective study, we present symptoms that led to diagnosis, treatments, fertility and obstetrical outcome.ResultsMean gestational age at diagnosis was 8 SA, with a median BHCG rate of 7411 IU/L, and a patient mean age of 30 years. Ninety percent of patients had at least one risk factor for ectopic pregnancy. Pain or bleeding were the most common symptoms at admission, 4 patients were admitted in an hypovolemic shock status. Location of the interstitial ectopic pregnancy was discovered during surgery in 45 % of cases. Six patients had a large hemoperitoneum bigger than 1 L, 5 patients had an IP of uterine stump after salpingectomy for a previous ectopic pregnancy. The most used surgical technique was in 60 % of cases the excision by Endo GIA stapling^® with salpingectomy. Regarding fertility, 12 patients wished pregnancy in the aftermath of the intervention, 10 had at least one pregnancy, among them there is an ectopic contralateral ampullary pregnancy, and a contralateral recurrence of interstitial pregnancy. Four patients were delivered by cesarean section and 4 patients were delivered vaginally, some several times. No uterine rupture occured.Discussion and conclusionInterstitial pregnancy is a rare ectopic pregnancy. Its diagnosis is difficult and may involve maternal life-threatening and fertility. In subsequent pregnancies, the clinician has to be careful concerning the risks of interstitial pregnancy recurrence and uterine rupture.     

CA125 decline in ovarian cancer patients treated with intravenous versus intraperitoneal platinum-based chemotherapy

ObjectivesTo compare the slope of CA125 decline in patients with optimally debulked epithelial ovarian cancer achieving a response to intravenous (IV) versus intraperitoneal (IP) platinum-based chemotherapy. The secondary objectives are to determine if the time to normal CA125 levels and time to nadir of CA125 differ between the groups.MethodsPatients with primary stage III, optimally cytoreduced ovarian cancer were stratified as to whether platinum and taxane chemotherapy was administered entirely IV (IV group), or whether it was given IV and IP (IP group). Inclusion criteria included an elevated CA125 prior to surgery or first cycle chemotherapy and at least 1 month follow-up after completion of chemotherapy. All patients had a complete or partial response. In addition, IP patients had to have received at least 1 cycle of IP chemotherapy. Because of the large range of CA125 levels, raw CA125 values were natural log transformed and compared using repeated measures analysis of variance (ANOVA).Results53 patients met inclusion criteria, 36 in the IV arm and 17 in the IP arm. The median number of chemotherapy cycles was 6 in both groups; the range was 5–9 in the IP arm and 6–10 in the IV arm. The median CA125 prior to surgery was 888 (range 45–5940) in the IP group and 1081 (range 58–19,440) in the IV group, p = 0.55. After surgery but prior to chemotherapy, the median CA125 was 175.5 in the IP arm (range 10.8–4035) versus 233.5 (range 16.5–6890) in the IV arm, p = 0.43. The median time to normalization of CA125 for the IP group was half the time of the IV group, 0.75 months (range 0 to 4.5) versus 1.5 months (range 0 to 6.25), p = 0.15. The time to nadir was slightly faster in the IP arm as compared to the IV arm, 4.5 months (2–10.5) versus 6 months (2–14), p = 0.13. The CA125 slopes were parallel, indicating that the CA125 levels declined at the same rate in both groups. However, the patients treated with IP chemotherapy had significantly lower CA125 levels over all the cycles, p = 0.02.ConclusionsContrary to the assumption that IP chemotherapy elevates CA125 levels due to peritoneal irritation, these results show a trend towards faster time to CA125 normalization and nadir, and significantly lower CA125 levels during therapy for patients responding to IP chemotherapy compared with patients responding to IV therapy.     

Identificación de factores que se asocian a alto riesgo de desarrollar diabetes gestacional

ObjectivesThe main objective is to determine the current prevalence of recognised risk factors for gestational diabetes mellitus (GDM) in our region, and to define the profile of patients at higher risk of developing this condition. We also investigate patient acceptability of the screening tests.Material and methodsThis is an ambispective study with 1,448 pregnant women recruited between December 2017 and July 2019 from a single centre. Inclusion criteria were no diabetes mellitus prior to the pregnancy, no history of GDM in any previous pregnancy, no history of bariatric surgery before the pregnancy, and GDM screening tests performed.ResultsThe prevalence of GDM was 6.7%. Risk factors associated with development of GDM were: age ≥ 27.5 years (OR: 3.8; 95% CI: 2.01-9.16); BMI ≥ 28.5 kg/m² (OR: 2.3; 95% CI: 1.47-3.59); history of diabetes mellitus in first-degree relatives (OR: 2.3; 95% CI: 1.5-3.66); and multiple pregnancy (OR: 2.8; 95% CI: 0.86-6.36); Prevalence of GDM increased with the number of risk factors presented by patients: from 1.4% with no risk factor, to 25.2% with 3. The O'Sullivan test (50 g glucose) and oral glucose tolerance test (100 g glucose) were perceived as “unpleasant” by 26.8% and 65.4% of patients, respectively.ConclusionsAge ≥ 27.5 years, BMI ≥ 28.5 kg/m², history of diabetes mellitus in first-degree relatives, and multiple pregnancy are factors related to an increased risk of GDM; these factors would be enough to identify most pregnant women developing GDM. Our findings may be used to improve programmes aimed at early diagnosis of gestational diabetes and supporting high-risk mothers in antenatal care.     

Can the preoperative HE4 level predict optimal cytoreduction in patients with advanced ovarian carcinoma?

ObjectiveOptimal surgical outcome has been proved to be one of the most powerful survival determinants in the management of ovarian cancer patients. Actually, for ovarian cancer patients there is no general consensus on the preoperatively establishment of cytoreducibility.MethodsBetween January 2011 and June 2012 patients affected by suspicious advanced ovarian cancer, referred to the Department of Gynecology of Campus Biomedico of Rome were enrolled in the study. All patients had serum CA125 and HE4 measured preoperatively. After a complete laparoscopy to assess the possibility of optimal debulking surgery defined as no visible residual tumor after cytoreduction (RT = 0), patients were submitted to primary cytoreductive surgery (Group A) or addressed to neoadjuvant chemotherapy (Group B).ResultsAfter diagnostic open laparoscopy, 36 patients underwent optimal primary cytoreductive surgery (Group A) and 21 patients were addressed to neoadjuvant chemotherapy (Group B). In our population, based on ROC curve, the HE4 value of 262 pmol/L is the best cut-off to identify patients candidates to optimal cytoreduction with a sensitivity of 86.1% and a specificity of 89.5% (PPV = 93.9% and NPV = 77%). In addition, CA125 has a sensitivity of 58.3% and a specificity of 84% at cut-off of 414 UI/mL (AUC is 0.68, 95% C.I. = 0.620 to 0.861).ConclusionOur data indicate that preoperative HE4 is a better predictor for optimal cytoreduction compared to CA125. The best combination in predicting cytoreduction is HE4 ≤ 262 pmol/L and ascites < 500 mL with a sensitivity of 100% and a specificity of 89.5% (PPV = 94% and NPV = 100%).     

Analysis of the Impact of Body Mass Index on the Surgical Outcomes after Robot-Assisted Laparoscopic Myomectomy

Study ObjectiveTo estimate the impact of body mass index (BMI) on surgical outcomes in patients undergoing robotic myomectomy.DesignA retrospective cohort data analysis (Canadian Task Force classification II-2).SettingCommunity-based teaching hospital.PatientsA total of 77 consecutive patients from January 2005 through November 2008 with symptomatic leiomyomata.InterventionRobotic-assisted laparoscopic myomectomy.Measurements and Main ResultsBody mass index ([BMI] expressed as kg/m²) was abstracted from the medical charts of all patients undergoing robotic myomectomy. Data on estimated blood loss, procedure time, length of hospital stay, diameter of the largest fibroid, and specimen weight were also extracted. Overall patient demographics between the groups were similar. Thirty-two patients (41.6%) were obese or morbidly obese (BMI > 30). The parameters analyzed for associations with the continuous measure of BMI included length of postoperative hospital stay (LOS), estimated blood loss (EBL), and procedure duration. Median (range) procedure time among all patients was (195 minutes, 98-653 minutes), estimated blood loss was (100 mL, 10-700 mL), and length of hospital stay was (1 day, 1-5 days). No associations were determined between BMI and LOS (r = 0.14, p = .22), EBL (r = 0.25, p = .03), or procedure duration (r = 0.16, p = .22) with Spearman correlations. The size of the largest leiomyoma diameter did not affect these associations.ConclusionPreoperative obesity is not a risk factor for poor surgical outcome in patients undergoing robotic myomectomy.