„Niche” a divertuculum of the myometrial cesarean section scar – etiology, diagnostics and symptoms

„Niche”, nowoopisywane w polskiej literaturze powikłanie po cięciu cesarskim, definiowane jest jako trójkątny bezechowy ubytek mięśniówki macicy w miejscu jej blizny po przebytym cięciu cesarskim wykonanym typowo w dolnym odcinku. Celem pracy jest zebranie danych literaturowych na temat rozpoznawania i objawów ubytku w bliźnie macicy po cięciu cesarskim. Diagnostyka tego zjawiska obejmuje badania obrazowe: ultrasonografię dopochwową umożliwiającą lokalizację blizny, oraz ultrasonografię z użyciem środka kontrastowego (sonohisterografię), stanowiącą metodę z wyboru do oceny głębokości lub wielkości ubytku, grubości mięśniówki nad nim oraz całkowitej grubości mięśniówki. Nie do końca jasne są przyczyny powstawania ubytku w bliźnie macicy, chociaż sugeruje się oddziaływanie wielu czynników, takich jak te związane z techniką zamykania warstwowego rany trzonu macicy, z wykształcaniem się dolnego odcinka trzonu macicy lub związane z procesem gojenia ran. Ubytek w bliźnie może stanowić problem kliniczny, objawiający się nieprawidłowymi krwawieniami macicznymi, bólami podbrzusza, niepłodnością, zaburzeniami mikcji oraz powikłaniami położniczymi stanowiącymi problem mogący zagrażać życiu i zdrowiu zarówno ciężarnej, jak i płodu. Wciąż niewyjaśniona jest sugerowana zależność między obecnością ubytku a powstawaniem powikłań w następnych ciążach jak rozejście blizny macicy w okresie okołoporodowym i umiejscowienie elementów jaja płodowego w okolicy ubytku.Niche, a newly described in the polish literature cesarean section complication, is defined as a triangular anechoic deficient of the uterine myometrium localized in the site of the scar after the incision of a typically performed low-transverse cesarean delivery. The aim of the paper is to provide an overview of the available literature on the diagnosis and symptoms of niche. Diagnostic evaluation of the niche comprises of visual diagnostic methods: transvaginal ultrasonography to localize the cesarean scar and contrast-enhanced sonography as the method of choice for measuring the depth of the niche, the residual myometrium thickness and the total myometrial thickness. The mechanisms of niche development have not yet been revealed, although, as suggested, it may be a coincidence of many factors as: closure technique, development of the lower uterine segment or location of the incision and wound healing. The symptoms related to the presence of a niche are: abnormal uterine bleeding, lower abdominal pain, infertility, urination problems and obstetrical complications which may be life-threatening for both the women and the fetus. The suggested relation between the niche and the occurrence of complications in future pregnancies, as uterine rupture and implantation of the gestational sack in the site of the diverticulum, are still unexplained

The influence of depth of marker administration on sentinel node detection in cervical cancer

BACKGROUND: Regional lymph node surgical management is an integral part of cervical cancer therapy. In gynaecological oncology, recent studies have confirmed the utility of the sentinel node concept in vulvar and cervical cancer. The method of the marker’s administration is considered to play an important role in sentinel node detection. MATERIAL AND METHODS: 60 patients with cervical cancer (stage IB–IIA) underwent SLN detection during radical abdominal hysterectomy. The patients were randomly divided into two groups: the first group of 30 patients with 0.5–1cm deep marker injection, the second with sub-epithelial marker injection. Gamma-camera scanning, as well as hand-held probe detection was applied. RESULTS: All hot nodes visualised on lymphoscintigraphy were “hot” when using the hand-held gamma probe. Deep marker injection revealed a sentinel node in 27 patients (90%) on both sides, in 3 patients (10%) only on one side. Only 40 (67%) sentinel nodes were blue-stained. Sub-epithelial marker administration revealed a sentinel node on both sides in all 30 patients (100%). In 28 patients (93.3%) the sentinel nodes were radioactive and blue-stained, in one case not-blue stained on either side, in one case blue stained only on one side. CONCLUSIONS: The sentinel node detection rate in cervical cancer is relatively high and depends on the applied technique. The superficial administration of radiocolloid and the blue dye into the cervix provides a higher sentinel node detection rate than deep administration in cervical cancer patients

The role of sentinel node detection techniques in vulvar and cervical cancer

The sentinel node is the first lymph node that receives the lymph drainage from the primary tumour. The pathological status of the sentinel node should reflect the histopathology of the entire regional lymph drainage area — both vulvar and cervical cancer spread through the lymphatic system. In gynaecological oncology recent studies have confirmed the utility of the sentinel node concept in vulvar and cervical cancer. Three techniques for sentinel node localisation are available. The preoperative lymphoscintigraphy and intraoperative handheld gamma probe detection require the administration of the technetium-99m-labelled colloid around the tumour. The other method is based on the injection of the patent blue dye — during the surgery of the sentinel node because of the dye uptake becomes visible. Following detection, the sentinel lymph node can be removed separately and assessed with ultrastaging and immunohistochemical staining. In the early stages of vulvar and cervical cancer the lymph nodes metastases rate is relatively low — in most cases lymphadenectomy is not necessary. The determination of the regional lymph nodes’ pathological status may limit the extent of the surgical treatment. The sentinel node detection rate is relatively high and depends on the applied technique. This technique may play an important role in the treatment of vulvar and cervical cancer. This paper describes the details of sentinel node identification and reviews the literature

Evaluation of sentinel node detection in vulvar cancer

BACKGROUND: In vulvar cancer, in a large portion of patients with early stages of the disease, the inguinal lymphadenectomy not only does not influence the overall survival and recurrence rate but may increase the incidence of complications. Sentinel lymph node (SN) detection is a promising technique for detecting groin lymph nodes, which may in future lead to less extensive use of surgical treatment. The aim of the study was to evaluate the feasibility of the sentinel node detection technique in patients with vulvar cancer. MATERIAL AND METHODS: Between the years 2003 and 2005, we performed intraoperative lymphatic mapping on 10 patients with planoepithelial vulvar cancer. In eight cases, vulvar lesion was localized centrally, around the clitoris. The extent of the surgery included radical vulvectomy with bilateral inguinal lymphadenectomy in nine cases and unilateral inguinal lymphadenectomy in one case. For the lymphatic mapping, we employed two detection methods: 99mTc-labelled radiocolloid (activity 35-70 MBq) and blue dye (3-5 ml). Both techniques were used in six cases (60%), blue dye only in three cases and radiocolloid only in one case. RESULTS: In each patient, we detected at least one sentinel lymph node. Sentinel nodes were localized in 14 of 19 operated groins (73.7%); a total of 25 SNs in all. The mean number of SNs for one groin was 1.78. Nodal metastases were found in four cases. In three cases, metastases were detected only in the SN. In one patient, two SNs with metastases were found in one groin and in the contralateral groin (without any SN) there was one unchanged node, which transpired to be metastatic. This can be explained by a complete overgrowth of neoplasm in the lymph node resulting in lymph flow stasis and disabling tracer uptake. In five cases, an SN was found only in one groin ó the first case is described above, in the second case the vulvar tumor was localized laterally, opposite to the groin without any SN. In the remaining three cases, we have used only one method of SN detection. CONCLUSIONS: Lymphatic mapping in vulvar cancer based on the combined detection technique is a highly accurate method after adequate training of the surgeons

Chemioterapia dootrzewnowa w raku jajnika

Chemioterapia dootrzewnowa (IPC) jest rodzajem leczenia uzupełniającego. Stosuje się ją najczęściej po zabiegucytoredukcji nowotworu złośliwego. Jej początki sięgają lat 50., kiedy to zaczęto ją stosować w przypadku rozsiewunowotworowego w jamie brzusznej. Współcześnie stanowi ona jedną z opcji leczniczych w przypadkach wielunowotworów. W artykule skoncentrowano się na kluczowych zagadnieniach dotyczących IPC oraz dootrzewnowejchemioterapii śródoperacyjnej w hipertermii (HIPEC) w raku jajnika. Przedstawiono aktualny stan wiedzy na temat IPCi HIPEC w tym nowotworze. Omówiono zagadnienia takie jak czas zastosowania IPC, uzasadnienie jej użycia, różnicew stosunku do chemioterapii dożylnej (IVC), podano korzyści i wady, w tym omówiono skuteczność, toksyczność,kwalifi kację do terapii oraz wymogi stawiane wobec ośrodka przeprowadzającego taką procedurę medyczną. Zwróconotakże uwagę na kwestie fi nansowe związane z IPC i HIPEC

The impact of low volume lymph node metastases and stage migration after pathologic ultrastaging of non-sentinel lymph nodes in early-stage cervical cancer: a study of 54 patients with 4.2 years of follow up

Objectives: To assess the significance of pathologic ultrastaging (PU) of sentinel (SLN) and non-sentinel (nSLN) lymph nodes (LNs) and the influence on cancer staging in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IB1 cervical cancer. Material and methods: A retrospective study was conducted with 54 patients divided into two equal-sized groups. In test group (n1), at least one SLN/patient was detected with blue dye. All excised LNs in this group were subjected to PU (4 μm slices/150 μm intervals) with hematoxylin-eosin staining and immunohistochemistry (AE1-AE3 antibodies). In none of the control group (n2) was PU performed, but in 2 patients SLN concept was performed. Patients in both groups underwent radical hysterectomy and lymphadenectomy. The effect of PU was expressed in puTNM and compared with both standard pTNM and FIGO systems. The influence of PU on patients’ disease-free survival (DFS) and overall survival (OS) was assessed using Kaplan-Meier curves. Results: In total, 516 LNs were extracted (66 SLNs, 36% bilaterally). Micrometastases (MIC) or isolated tumor cells (ITC) were detected in 34 of the 482 LNs (7.1%), including 16 MICs and 9 ITC in non-SLNs. False negative rates were: 3.7%/side-specific, and 7.4%/both sides. The use of PU resulted in stage change in 2 cases (N and M status change), FIGO stage did not changed. No PU impact on DFS or OS was observed. Conclusions: The risk of TNM stage migration in early cervical cancer is low, is more likely in inattentively evaluated patients, and has indeterminate prognostic and predictive value. Selection of cases with cT ≤ 2 cm and cN0 is sufficient to avoid the risk of improper staging

Multiple multiparity is a negative prognostic factor for endometrial cancer in Poland

Cel: Nierództwo jest jednym z najważniejszych czynników ryzyka rozwoju raka błony śluzowej trzonu macicy. Wciąż trwają rozważania, czy wielorództwo implikuje bardziej korzystny przebieg choroby i wyższe współczynniki całkowitego przeżycia chorych. Celem pracy jest ocena wpływu rodności na całkowite przeżycie kobiet w Polsce z rakiem błony śluzowej trzonu macicy. Materiał i metody: Retrospektywna analiza wpływu rodności na współczynniki przeżycia została przeprowadzona u 810 kobiet leczonych operacyjnie z powodu raka błony śluzowej trzonu macicy w ośrodku referencyjnym ginekologii onkologicznej. Wyniki: Wykazano, że wyższa rodność jest związana z istotnie niższym współczynnikiem całkowitego przeżycia chorych (p=0.03). Rodność okazała się być niezależnym czynnikiem przeżycia chorych (HR 1.9). Wielokrotne wieloródki były starsze w chwili zabiegu operacyjnego, stwierdzano u nich częściej głębokie naciekanie mięśniówki macicy i częściej naciek podścieliska szyjki macicy oraz wyższe stopnie zaawansowania nowotworu (wyłącznie w klasyfikacji FIGO z 1988 roku). Grupa wielokrotnych wieloródek charakteryzowała się znacząco niższym współczynnikiem nawrotów choroby. Kobiety te statystycznie częściej cechowało posiadanie niższego wykształcenia, częściej również stwierdzano u nich obecność chorób towarzyszących w tym również występowanie innych nowotworów złośliwych. W grupie tej jednakże rzadziej występowały nowotwór piersi i jelita grubego niż u pozostałych kobiet. Wnioski: Wielorództwo okazuje się być niekorzystnym czynnikiem prognostycznym przeżycia u Polek. Niekorzystne rokowanie w raku błony śluzowej trzonu macicy w tej grupie jest mniej związane z nierództwem a zdecydowanie bardziej związane z interakcją niekorzystnych czynników ryzyka i negatywnych czynników prognostycznych, które tworzą sprzyjające okoliczności i środowisko dla wzrostu nowotworu.  Background: Nulliparity is one of the most important reproductive risk factors for endometrial cancer. It is still discussed whether multiparity implies a more favorable course of the disease and higher overall survival rates. The aim of the study was to analyze the effect of parity on the overall survival of endometrial cancer patients in Poland. Material and method: A retrospective analysis of parity on survival rates was performed in 810 women treated surgically for endometrial cancer in a single referential center of gynecological oncology. Results: Higher parity was shown to be associated with significantly lower survival rates (p=0.03). Parity turned out to be an independent prognostic factor of survival (HR 1.9). Multiple multiparous women were older at the time of surgery, more often presented with deep myometrial infiltration and with involvement of the cervical stroma and had higher clinical stages of the cancer (only according to FIGO 1988 classification). The group of multiple multiparous women was characterized by significantly lower recurrence rates. Multiple multiparous women significantly more often presented with lower educational level, more often were diagnosed with comorbidities and a history of other malignancies, while breast cancer and colon cancer were of lesser evidence in multiple multiparous endometrial cancer patients. Conclusion: Multiparity turns out to be an unfavorable prognostic factor of survival in Polish women. Unfavorable prognosis in endometrial cancer patients in this group is associated with interactions between risk factors and negative prognostic factors, i.e. the conditions of tumor growth, rather than with the nulliparity itself.

Guidelines from the Polish Surgical Society and Polish Society of Oncological Surgery Concerning Quality Assurance for Centres Performing Cytoreductive Procedures and HIPEC Procedures in the Treatment of Primary and Secondary Peritoneal Tumours

Surgical treatment of patients with peritoneal metastases in combination with Hyperthermic intraperitoneal Chemotherapy (HIPEC) and systemic treatments is applied with increasing frequency and, with correct patient qualification, allows for obtaining 5-year survival at a level of 32–52%. The conditions necessary for positive results of such treatment include the high experience of a given centre, its appropriate infrastructure, and appropriate patient qualification for the procedure. As a result of the debate connected with the need to evaluate treatment quality and results, at the request of the Peritoneal Cancer Section of the Polish Society of Oncological Surgery, the conditions for quality assurance were worked out and a Quality Assurance Commission was set up for the centres performing cytoreductive procedures and HIPEC procedures in the treatment of primary and secondary peritoneal tumours

Central Pathology Review in SENTIX, a Prospective Observational International Study on Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer (ENGOT-CX2)

The quality of pathological assessment is crucial for the safety of patients with cervical cancer if pelvic lymph node dissection is to be replaced by sentinel lymph node (SLN) biopsy. Central pathology review of SLN pathological ultrastaging was conducted in the prospective SENTIX/European Network of Gynaecological Oncological Trial (ENGOT)-CX2 study. All specimens from at least two patients per site were submitted for the central review. For cases with major or critical deviations, the sites were requested to submit all samples from all additional patients for second-round assessment. From the group of 300 patients, samples from 83 cases from 37 sites were reviewed in the first round. Minor, major, critical, and no deviations were identified in 28%, 19%, 14%, and 39% of cases, respectively. Samples from 26 patients were submitted for the second-round review, with only two major deviations found. In conclusion, a high rate of major or critical deviations was identified in the first round of the central pathology review (28% of samples). This reflects a substantial heterogeneity in current practice, despite trial protocol requirements. The importance of the central review conducted prospectively at the early phase of the trial is demonstrated by a substantial improvement of SLN ultrastaging quality in the second-round review