Jatupol Srisomboon

Objective: To evaluate treatment outcomes and prognostic factors in patients with ultra-high-risk gestational trophoblastic neoplasia (GTN) compared to those with low-risk and high-risk GTN. Methods: A retrospective review of medical records was conducted for GTN patients treated at Chiang Mai University Hospital, Chiang Mai, Thailand, between January 1999 and December 2019. Overall and risk-specific survival rates were estimated using the Kaplan–Meier method, and prognostic factors were analyzed through univariate and multivariate analyses. Results: During the study period, 160 patients with GTN were identified, including 98 (61.2%) classified as low-risk, 31 (19.4%) as high-risk, and 31 (19.4%) as ultra-high-risk. One patient in the low-risk group and one in the high-risk group underwent hysterectomy without adjuvant chemotherapy due to spontaneous regression of serum β-hCG (human chorionic gonadotropin). Additionally, one patient with ultra-high-risk GTN died before receiving chemotherapy. Among the 97 low-risk GTN patients, 80 (82.5%) were treated with either single-agent methotrexate or actinomycin D. Among the 30 high-risk GTN patients, 20 (66.7%) received EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine) as first-line chemotherapy, while 24 (80%) of the 30 ultra-high-risk GTN patients received EMA/CO as first-line treatment. Following first-line chemotherapy and/or salvage treatment, patients with ultra-high-risk GTN had significantly worse outcomes compared with those with low- and high-risk GTN, with remission rates of 63.3%, 96.9%, and 80.0%, respectively (p < 0.01). The five-year overall survival rate for patients with ultra-high-risk GTN was significantly lower than that for patients with low- and high-risk GTN (56% vs. 96% and 80%, respectively; p < 0.001). On multivariable analysis, significant prognostic factors included antecedent term pregnancy (hazard ratio [HR] = 11.50; 95% confidence interval [CI], 3.56–37.22; p < 0.01) and brain metastasis (HR = 4.61; 95% CI, 1.73–12.28; p < 0.01). Conclusions: Ultra-high-risk GTN accounts for only a small proportion of GTN cases but it is associated with poor survival rate and responsible for the majority of GTN-related deaths. Antecedent term pregnancy and brain metastasis were identified as significant prognostic factors.

OBJECTIVE The primary objective was to determine the 5-year overall survival rate and 5-year disease-free survival rate of patients with CACx 1A1 treated at Chiang Mai University Hospital and the secondary objective was to describe treatment modalities as well as their associated complications. METHODS Patients with stage IA1 cervical cancer diagnosed from January 2001 to June 2018 at Chiang Mai University Hospital were retrospectively reviewed. Inclusion criteria included previously untreated patients diagnosed with stage IA1 cervical cancer (2018 FIGO staging system). Exclusion criteria were patients with recurrent cervical cancer, other gynecologic malignancies, and those in a pregnant state. The analysis included treatment patterns, surgical types, and clinicopathologic variables, i.e., nodal metastasis, parametrial involvement, positive surgical margins, deep stromal invasion (DSI), lymph-vascular space invasion (LVSI), adjuvant treatment, 5-year disease-free survival, and 5-year overall survival. All pathologic slides were reviewed by gynecologic pathologists. The Kruskal-Wallis test, Fisher’s exact test, the Kaplan-Meier method and log-rank test were used for statistical analysis. RESULTS Of the 184 patients included in this study, simple hysterectomy was the most common treatment (57.3%), followed by modified radical hysterectomy (MRH) and radical hysterectomy (RH) (27.6% and 9.7% respectively). Conization and radiation were chosen in a few cases. At the median follow up time of 40.8 months, the 5-year disease free survival rate was 99.1% and the 5-year overall survival rate was 95.0%. Pelvic lymph node dissection was done in 62 cases (33.7%), but only one case (0.54%) had pelvic lymph node metastasis. CONCLUSIONS The surgical and survival outcomes for women with stage IA1 cervical cancer are excellent. They can be effectively treated with less radical interventions such as simple hysterectomy and conization. Lymph node metastasis is rare at this stage (0.54%); therefore, lympha-denectomy may possibly be omitted. KEYWORDS cervical cancer, IA1, treatment outcome

Lertkhachonsuk AA, et al. J Gynecol Oncol. 2022 Jan;33:e36. https://doi.org/10.3802/jgo.2022.33.e36

Background. Shoulder pain is a common symptom following laparoscopic surgery. This systematic review was undertaken to assess updated evidence regarding the effectiveness and complications of the pulmonary recruitment maneuver (PRM) for reducing shoulder pain after laparoscopic gynecologic surgery. Methods. A number of databases for randomized controlled trials (RCTs) investigating PRM for reducing shoulder pain were searched up to June 2019. Two authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, and compared results. Network meta-analyses were employed to simultaneously compare multiple interventions. Effect measures were presented as pooled mean difference (MD) or risk ratio (RR) with corresponding 95 confidence intervals (CI). Results. Of the 44 records that we identified as a result of the search (excluding duplicates), eleven RCTs involving 1111 participants were included. Three studies had an unclear risk of selection bias. PRM with a maximum pressure of 40cm H₂O was most likely to result in the lowest shoulder pain intensity at 24 hours (MD 1.91; 95 CI 2.06 to 1.76) while PRM with a maximum pressure of 40cmH₂O plus intraperitoneal saline (IPS) appeared to be the most efficient at 48 hours (MD 2.09; 95 CI 2.97 to 1.21). The estimated RRs for analgesia requirement, nausea/vomiting, and cardiopulmonary events were similar across the competing interventions. Conclusion. PRM with 40cm H₂O performed either alone or accompanied by IPS is a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy.

Background: With increasing rates of cesarean sections (CS), the number of hysterectomies performed among women with a previous CS is on the rise. Objective: To provide the association between the odds of complications following a hysterectomy performed later in life and a previous CS. Search strategy: A comprehensive search was performed using major electronic databases, ie, MEDLINE, Scopus, ISI Web of Science, from their inception to April 2019. Selection criteria: Analytical studies, irrespective of language or publication status, were included. Data collection and analysis: Outcomes were extracted in duplicate. The methodological quality of the included studies was independently evaluated by two review authors. A three-level meta-analysis was applied for outcomes with dependent effect sizes. Main results: Twenty-six studies were included involving 54,815 women. The odds of the following complications were increased in women with a previous CS: urinary tract injury (pooled unadjusted odds ratio (OR)=3.15, 95% CI=2.01–4.94, 15 studies, 33,902 women, and pooled adjusted OR=2.21, 95% CI=1.46–3.34, 3 studies, 31,038 women), gastrointestinal tract injury (pooled unadjusted OR=1.73, 95% CI=1.19–2.53; 7 studies, 30,050, and pooled adjusted OR=1.83, 95% CI=1.11–3.03, 1 study, 25,354 women), postoperative infections (pooled unadjusted OR=1.44, 95% CI=1.22–1.71, 6 studies, 37,832 women), wound complications (pooled unadjusted OR=2.24, 95% CI=1.94–2.57, 9 studies, 37,559 women), reoperation (pooled unadjusted OR=1.46, 95% CI=1.19–1.78, 2 studies, 9,899 women), and blood transfusion (pooled unadjusted OR=1.35, 95% CI=1.03–1.76, 7 studies, 13,430 women). Conclusion: Previous CS increases risks of various complications following hysterectomy. This information reminds the gynecologists to be aware of the associations between previous CS and potential complications among women undergoing hysterectomy. Prospero registration number: CRD42018085061.

Tangjitgamol S, et al. J Gynecol Oncol. 2019 Apr;30(4):e82. https://doi.org/10.3802/jgo.2019.30.e82