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Objective: Complex procedures such as distal pancreatectomy and splenectomy (DPS) may be required for R0 resection in patients with ovarian cancer (OC). These procedures can increase survival and cause serious morbidity. We aimed to present our experience in this field., Materials and Methods: Thirteen patients who underwent DPS for OC between January 2004 and July 2018 in two centers (Hacettepe University Hospital, Etlik Hospital) were evaluated. Statistical analysis was performed using SPSS., Results: The mean operative time was 310 min (220-570 min). None of the patients required transfusion. No perioperative mortality was observed. The mean postoperative hospital stay was 12 days (ranging from 8 to 33 days). The number of patients with early postoperative complications was four (30.7%). One of these patients was complicated by intestinal perforation, one with pancreatic fistula, one with pneumonia and the other with atelectasis. Other complications were observed conservatively. Ten patients underwent 6 cycles of platinum-based chemotherapy postoperatively. The median value of the postoperative chemotherapy period was 20 days (range 11-47 days). The median follow-up period was 46 months (2-144 months). Ten patients had recurrence. Eleven patients died of disease. Two patients are stil alive. Disease-free (DFS) and overall (OS) survival were 16 and 63 months, respectively., Conclusion: DPS for cytoreductive surgery is a procedure that increases morbidity, but most of the complications can be treated conservatively. Considering the increase in survival, it is considered to be a valuable procedure in upper abdominal disease., Competing Interests: Declaration of competing interest Authors declare that they have no conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: To investigate the clinico-pathological prognostic factors and treatment outcomes in patients with ovarian yolk sac tumors (YST)., Methods: A multicenter, retrospective department database review was performed to identify patients with ovarian YST who underwent surgery between 2000 and 2017 at seven Gynecologic Oncology Centers in Turkey., Results: The study group consisted of 99 consecutive patients with a mean age of 23.9 years. While 52 patients had early stage (stage I-II) disease, the remaining 47 patients had advanced stage (stage III-IV) disease. The uterus was preserved in 74 (74.8%) of the cases. The absence of gross residual disease following surgery was achieved in 76.8% of the cases. Of the 54 patients with lymph node dissection (LND), lymph node metastasis was detected in 10 (18.5%) patients. Of the 99 patients, only 3 patients did not receive adjuvant therapy, and most of the patients (91.9%) received BEP (bleomycin, etoposide, cisplatin) chemotherapy. Disease recurred in 21 (21.2%) patients. The 5-year disease-free survival (DFS) and overall survival (OS) in the entire cohort were 79.2% and 81.3%, respectively. In multivariate analysis, only residual disease following initial surgery was found to be significantly associated with DFS and OS in patients with ovarian YST (p = 0.026 and p = 0.001, respectively)., Conclusions: Our results demonstrate the significance of achieving no visible residual disease in patients with ovarian YST. Fertility-sparing approach for patients with no visible residual disease affected neither DFS nor OS. Although high lymphatic involvement rate was detected, the benefit of LND could not be demonstrated.

Objective: To investigate the incidence of retroperitoneal lymph node metastasis among patients with primary adult type granulosa cell tumor (AGCT) of the ovary., Study Design: Between January 1982 and February 2017, patients with a pathological diagnosis of AGCT were identified. Clinical and pathological data were obtained from database records., Results: A total of 151 patients with primary AGCT were identified with a mean age of 47.8 years (range, 17-91 years). 98 patients (64.9%) had stage IA, 24 (15.9%) had stage IC, 4 (2.6%) had stage IIB, 2 (1.3%) had stage IIIB, 6 (4.0%) had stage IIIC disease according to International Federation of Gynecology and Obstetrics (FIGO) 1988 criteria. In the remaining 17 patients (11.3%), primary stage was not detected. In 134 (88.7%) patients, pelvic and para-aortic lymphadenectomy was performed at primary staging surgery depending on the frozen section analysis or at re-staging surgery following initial diagnosis. In these patients, six (4.5%) of them had pelvic or paraaortic lymph node metastasis. The median number of lymph nodes removed was 43 (range, 10-96 lymph nodes)., Conclusion: Lymph node metastasis in initially staged AGCT is rare. Routine pelvic and paraaortic lymph node dissection may be omitted in these patients., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To investigate clinicopathological characteristics and oncological outcome of women with microinvasive BOTs., Methods: A retrospective multicenter case-control study was conducted on 902 patients with BOT, who underwent surgery from January 2002 to December 2015 at six participating gynecologic oncology centers from Turkey. Among 902 patients, 69 had microinvasive BOT. For every patient with microinvasive BOT, two controls were randomly selected from another database based on decade of age and stage of disease at diagnosis. The clinical-pathological characteristics and oncological outcomes were compared between BOT patients with and without stromal microinvasion. Risk factors for poor oncological outcomes were investigated in a multivariate analysis model. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method., Results: Patients with microinvasive BOT had a significantly higher rate of recurrence than patients without microinvasive BOT (17.4 vs 7.8%, OR 3.55, %95 CI 1.091-11.59, p = 0.03). Stage at diagnosis (stage I versus II/III) and type of surgery (cystectomy versus others) were found as other significant prognostic factors for recurrence in multivariate analysis (OR 8.63, %95 CI 2.48-29.9, p = 0.001 and OR 19.4, %95 CI 3.59-105.6, p = 0.001, respectively). Stromal microinvasion was found as a prognostic factor for significantly shorter DFS (26.7 vs 11.9 months, p = 0.031, log rank). However, there was no significant difference in OS between two groups (p = 0.99, log rank)., Conclusion: Stromal microinvasion is significantly associated with decreased DFS. In addition, our study confirms that the risk of recurrence is higher in patients with microinvasive BOT.

Background and Objectives: There is still no any data about the role of re-operation and re-debulking in previously incompletely operated advanced staged patients with epithelial ovarian carcinoma (EOC). In this study, the authors aimed to analyze the effect of an incomplete primary surgery on patient prognosis., Methods: Clinicopathological variables of 317 advanced staged EOC patients were retrospectively collected., Results: Twenty-nine patients had an initial incomplete surgery and referred to our center for debulking while remaining 288 had undergone primary debulking surgery at our institution. Comparison of the two groups with respect to clinicopathological variables could not reveal significant difference. Median survival was 3.24 years for re-operated patients while it was 2.07 years for patients who had undergone primary debulking surgery. Upon multivariate analysis, final optimal debulking, tumor grade and a history of an incomplete surgery before the final debulking were the significant prognosticators. A subgroup analysis of re-staged patients could not reveal a significant role for either the type or the time interval between the operations., Conclusion: A history of an incomplete primary surgery does not seem to adversely affect patient prognosis and the optimal cytoreductive success achieved in final debulking surgery is still the most important prognostic factor.

Objective: To evaluate the impact of tertiary cytoreductive surgery (TCS) on patient survival and to determine predictors of optimal TCS., Methods: Twenty patients with recurrent epithelial ovarian carcinoma who had TCS at Hacettepe University Hospital during 1992-2004 were retrospectively reviewed., Results: Tertiary cytoreductive attempt was successful (optimal defined as <2 cm residual) in 12 patients and suboptimal in the remaining eight patients. Seven patients had no macroscopic residual, five patients had <2 cm gross residual and remaining 8 patients had >or=2 cm gross residual disease. Of these alive patients, 10 patients were alive with metastatic disease and only three patients were alive without any evidence of disease. Three patients had operative morbidity (15%), all of which were mild-moderate degree. Multivariate analysis could not differentiate a unique significant factor to have a possible predictor effect of optimal TCS. Multivariate survival analysis also could not differentiate any factor to have significant effect upon patient survival, neither the outcomes of primary, secondary or tertiary cytoreductive surgeries nor the usage of preoperative or postoperative chemotherapies., Conclusion: TCS may not be helpful for patient survival. Neither of the clinical factors predicted an optimal TCS. Further larger series are needed for a definite conclusion., ((c) 2008 Wiley-Liss, Inc.)

Aim: Depth of appendiceal metastasis in patients with epithelial ovarian carcinoma (EOC) has not been previously analyzed for a possible relationship with clinico-pathological variables., Methods: Sixty-nine patients with EOC treated at Hacettepe University were retrospectively analyzed. All of the patients had appendiceal metastasis. Pathological slides were re-reviewed by the same pathologist. Appendiceal metastases were defined as serosal (if tumoral spread involved only serosa of the appendix) or sero-mucosal (if tumoral spread also involved either muscular or mucosal surfaces of the appendix). Univariate and multivariate analysis did not reveal a significant difference with respect to the prognostic variables between the groups., Results: Thirty-nine patients had serosal appendiceal metastasis (56.5%), while the remaining 30 patients (43.5%) had appendiceal metastasis extending toward the muscular layer (seromucosal metastasis: 16 within muscularis mucosa, 14 within the mucosa of the appendix). The mean age at the time of diagnosis was 54.58 years (range, 26-88 years), with no significant difference between the groups (P = 0.9). Comparison of the survival rates between the two groups did not reveal a significant difference. Three-year survival rates were 23.3% in the serosal metastasis and 27.9% in the seromucosal metastasis group (P = 0.9). This figure was 25% for patients with only muscular metastasis and 41.6% for patients with appendiceal metastasis extending to the mucosal layer (P = 0.2)., Conclusion: This is the first report to analyze the metastatic pattern of EOC on the appendix with respect to depth of invasion which could not reveal a significant difference.

Background and Objectives: To analyze the predictors and outcomes of recurrent disease in patients with epithelial ovarian carcinoma (EOC) after a negative second look laparotomy (SLL)., Methods: One hundred nine EOC patients with a negative SLL treated at Hacettepe Hospital were retrospectively analyzed., Results: Of these patients, 70 (64.2%) had no evidence of disease during follow up while remaining 39 (35.8%) had recurrence. Majority of the recurrences (82.1%) were detected within the initial 2 years of the SLL procedure. Multivariate analysis revealed stage and grade of the disease to be the significant predictors for the recurrent disease (P < 0.01 and P = 0.025, respectively). A second analysis with respect to initial metastatic sites revealed omental metastatis was significantly associated with recurrent disease (P < 0.001). Survival of patients with a recurrent disease was significantly poorer and dropped abruptly once a recurrence is developed., Conclusions: Patients with initial omental metastasis, advanced stage and high grade tumors have highest risk for developing recurrences after a (-) SLL. Most of the recurrences develop during the initial 2 years following the (-) SLL and survival drops to less than 2 years once a recurrence is found., (2007 Wiley-Liss, Inc)

Objective: To analyze the clinicopathological correlations of metastatic lymph node (LN) numbers in patients with epithelial ovarian carcinoma., Method: A total of 328 patients with epithelial ovarian carcinoma diagnosed and treated at Hacettepe University Hospital during 1982-2005 were retrospectively reviewed. Patients' age, number of resected lymph nodes, clinical disease stage, preoperative Ca-125 levels, peritoneal cytology, presence of ascites, tumor histology, tumor grade, maximal tumor diameter, cytoreductive success, overall and disease-free survivals were compared with respect to the number of metastatic lymph nodes (< 4 vs. > or = 4)., Results: The mean number of resected lymph nodes was 24.5 and mean number of metastatic lymph nodes was 6.2. About 47.3% (n=155) of the patients had < 4 metastatic lymph nodes and the remaining 52.7% of patients (n=173) had > or = 4 metastatic lymph nodes. Univariate comparison of the two groups relived preoperative Ca-125 values, peritoneal cytology and clinical disease stage to be significantly different among the two groups. However, multivariate analysis revealed a high Ca-125 level (> or = 500 IU/l) to be unique factor significantly different among the groups. Survival analysis also could not find a significant difference with respect to overall and disease-free survival among the groups., Conclusion: The number of metastatic lymph nodes increases as the preoperative Ca-125 values increase. Other patient characteristics do not have a significant effect on the number of metastatic lymph nodes. Metastatic LN number does not have a prognostic significance in terms of either the overall or the disease-free survival. Prospective series are needed for a definitive conclusion.

Objective: The purpose of this study was to define risk factors associated with the occult metastasis in early stage epithelial ovarian carcinoma (EOC), and to compare the survivals in respect to occult metastasis., Study Design: A retrospective review of 169 patients with clinically early stage EOC was performed., Results: Overall, 53 patients (53/169, 31.4%) were upstaged. The most common occult metastasis was the lymphatic involvement (22/53; 41.5%). Overall, 64.1% (34/53) of these upstaged patients had unrecognized disease in the upper abdomen or retroperitoneal space. Multivariable analysis revealed 3 factors to be associated with occult metastasis: Ca-125 levels > or = 500 U/mL (P = .04), positive peritoneal cytology (P = .001), and grade III disease (P = .04). Five-year survival rates were 61.83% and 88.25%, respectively, in patients with or without occult metastasis. Among the upstaged patients, omental or peritoneal metastasis revealed the worst prognosis., Conclusion: Proper surgical staging is an important issue in early stage ovarian cancers, particularly in patients with high Ca-125 levels, positive cytology, and high grade tumor.

Objective: This study was undertaken to evaluate the role of secondary cytoreduction in patients with recurrent epithelial ovarian cancer., Study Design: Secondarily, cytoreduced patients were retrospectively analyzed with respect to the clinicopathologic variables., Results: A total of 64 patients were evaluated in this report. Multivariable analysis revealed 3 factors to be significant: optimal cytoreduction during primary (P = .003, odds ratio [OR]: 0.30; 95% CI: 0.14-0.66), secondary cytoreduction (P = .04, OR: 0.47; 95% CI: 0.22-0.99), and the endometrioid histologic type (P = .005, OR: 0.09; 95% CI: 0.02-0.48). Intrinsic factors of the tumors (grade, stage, age), size, and number of recurrent tumors were nonsignificant., Conclusion: Secondary cytoreductive surgery should be offered in selected recurrent epithelial ovarian cancer patients. Further prospective randomized series are needed to determine specific recommendations.

Objective: The purpose of this study was to evaluate the treatment regimens used for patients with endodermal sinus tumors (EST), and also to examine the prognostic value of surgicopathological variables., Study Design: Twenty-two patients treated for pure EST, and seven patients who had mixed germ cell tumors with EST components were included. Initial surgery consisting of surgical staging to achieve optimal debulking was the principal mode of therapy. Data were obtained from patients' files, a special gynecologic oncology database, and pathology records., Results: The median age at the time of diagnosis was 18 (range 8-45). Sixteen patients had stage I (55%), and 13 (45%) had stage II-IV disease. As an adjuvant therapy 18 patients (62%) received platin-based chemotherapy, three patients (10%) had non-platin-based chemotherapy, four patients (14%) had radiotherapy, and four patients (14%) had combined radiotherapy plus non-platin-based chemotherapy. The 5-year disease-free and overall survival rates were 47 and 48%, respectively. Survival rates were dismal in patients with stage II-IV disease (P < 0.001). Platin-based chemotherapy achieved significant survival benefit (P = 0.03 and P < 0.001, respectively). Fertility-saving surgery had an overall survival no worse than those who underwent more extensive surgery. There was no significant survival difference with respect to age, histology, and tumor size., Conclusion: Fertility-sparing surgery with a postoperative platin-based combination chemotherapy should be the selected mode of treatment.

Objective: The purpose of this study was to evaluate the prognostic factors, and the patterns of lymphatic metastasis in EOC patients who were treated with systematic pelvic and paraaortic lymphatic dissection., Methods: A total of 420 EOC patients was retrospectively evaluated. Clinical factors available were evaluated for a possible significance in terms of lymphatic metastasis and paraaortic involvement., Results: Two-hundred and three patients were found to have lymphatic metastasis. In multivariable analysis, stage (P < 0.001), histology (P < 0.01 for serous; P = 0.02 for mixed, and P = 0.04, for Brenner), and Ca-125 level higher than 500 U/ml (P = 0.04) were found to be significantly related with the lymphatic involvement. Age and grade were significant factors for paraaortic metastasis both in univariable and multivariable analysis (P = 0.003 and P = 0.02, respectively). Most of the patients with unilateral tumors had contralateral pelvic and/or paraaortic metastasis. There were eleven patients with lymphatic metastasis in stage I-II disease, and five had paraaortic metastasis while an additional five patients had contralateral pelvic nodal metastasis. However, there was no lymphatic involvement in Stage IA, Grade I-II disease (0/63). Survival analysis revealed no significant difference by the number of metastatic lymph nodes., Conclusion: In multivariable analysis, lymphatic involvement was predicted independently by stage, histology, and Ca-125 level. In apparently stage I-II disease, a considerable part of patients were upstaged due to lymphatic involvement. Although routine systematic lymphadenectomy is suggested for patients with early stage disease, further series are needed for a definite regimen in patients with stage IA G1-2 disease since we did not detect any lymphatic involvement in this unique group.

Objective: To detect risk factors for the appendiceal metastasis and to define the role of routine appendectomy in patients with epithelial ovarian carcinoma., Methods: A total of 285 patients with epithelial ovarian carcinoma who had undergone primary cytoreductive surgery including appendectomy were retrospectively evaluated. Appendiceal involvement was divided into 2 groups: gross and microscopic. Clinicopathologic variables were evaluated for possible significance in terms of appendiceal metastasis. A second analysis was performed using the same variables to detect a possible relation with microscopic metastasis. In a subgroup analysis, we also analyzed the role of routine appendectomy in patients with clinically early stage disease., Results: One-hundred six patients were found to have appendiceal metastasis (37%). Univariate and multivariate analysis revealed stage of disease as the unique factor determining the appendiceal metastasis (P < .001). Five patients with apparently stage I-II disease were upstaged due to isolated appendiceal metastasis (4.9%). In the second analysis excluding the patients with gross involvement, ascites was an independent predictor of microscopic involvement (P < .01)., Conclusion: Routine appendectomy is indicated in all epithelial ovarian carcinoma patients as part of the initial surgical staging procedure because of a considerable rate of upstaging in early stage disease and optimal cytoreduction in advanced stages., Level of Evidence: II-3.

Epithelial ovarian neoplasms can be divided into two major categories on the basis of their pathological and clinical behaviors: invasive ovarian tumors and borderline ovarian tumors. However, neither the etiology nor the pathogenesis of the borderline and invasive epithelial ovarian carcinomas has been understood completely. Borderline tumors are clearly more favaroble in terms of survival. The same pathological types can be seen both in borderline and invasive tumors. However; it is not clear if both diseases is a continuum of the same entity or are independent clinical entities. On the other hand, several in vivo and in vitro studies have demonstrated that overexpression of the cyclooxygenase-2 (COX-2) may have an important role in the development and the aggressive clinical behaviors of different malignancies. Furthermore, some recent studies have also revealed the overexpression of COX-2 in invasive epithelial ovarian carcinomas. In this manuscript, we propose that lower expressions of COX-2 may have a role in the development of borderline ovarian neoplasias, whereas higher levels have a role in the invasive epithelial ovarian cancers and this may be the basis for the clinical difference of both entities. To test this hypothesis; genetic, pathologic and epidemiologic studies may be performed. Patients with borderline tumors should be compared with the invasive counterparts in terms of COX mutations and expressions. Also, epidemiologic studies may reveal the role of COX inhibitors in the ovarian carcinogenesis. If this hypothesis is proven to be true, this may direct the clinicians to use prophylactic NSAIDs with or without combined oral contraceptives especially in high risk patients. Also, this hypothesis may enlight a new gene therapy targeting COX-2 gene in high risk patients for the development of EOC.

Objective: To evaluate the significance of preoperative platelet counts in advanced epithelial ovarian cancer with respect to second-look laparotomy results and disease progression., Methods: We prospectively evaluated 37 consecutive patients with advanced epithelial ovarian cancer who underwent primary surgical treatment. In addition to platelet counts, all patients were evaluated with respect to age, gravida, parity, and stage and grade of tumor. Thirty-six patients had stage III, and 1 patient had stage IV disease. Optimal debulking (diameter of residual tumor, less than 1 cm) was performed in all patients who subsequently received adjuvant chemotherapy (platin-paclitaxel). According to second-look laparotomy and follow-up results patients were divided into 2 groups. The first group had negative second-look laparotomy or no evidence of disease during follow-up (n = 20), and the second group had positive second-look laparotomy or progressive disease (n = 17). Sensitivity and specificity values were calculated for different cutoff values of platelet counts with receiver operating characteristic curve analysis., Results: Age, gravida, and parity were not significantly different compared with controls (P >.05). Mean platelet counts were 371 x 109/L and 446 x 109/L in the first and second groups, respectively (P =.03). Different cutoff values of platelet counts for the diagnosis of thrombocytosis were evaluated. A cutoff value of 380 x 109/L had sensitivity 77% and specificity 60% for recurrence, whereas a cutoff value of 400 x 109/L had sensitivity 59% and specificity 65%. Area under the curve (+/- standard error) was 0.72 +/- 0.08 (P =.026)., Conclusion: In patients with progressive disease and positive second-look laparotomy, preoperative platelet counts were significantly higher compared with patients with no evidence of disease on follow-up.