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Purpose The aims of the present study were to evaluate the development of untreated cervical intraepithelial neoplasia (CIN) 3 during pregnancy and to assess persistence, progression, and regression rates postpartum to identify factors associated with regression. Methods In a tertiary gynecology and obstetrics department, a total of 154 pregnant women with CIN 3 were treated in the dysplasia unit. The follow-up findings were analyzed retrospectively on the basis of histological, cytological, and human papillomavirus (HPV) testing of 154 pregnant women confirmed as having CIN 3 in colposcopically guided biopsies. Results The rates of persistence, regression, and progression of CIN 3 in these women were 76.1%, 20% and 3.2%, respectively. Data for the delivery mode was available for 126 women. The rate of regression was almost twice as high with vaginal delivery as with cesarean section, at 27.4 vs. 15.2%, whereas the rate of progression was lower with vaginal delivery, at 2.7 vs. 6.5%. Conclusion The rate of persistence of CIN observed in this study is comparable to that reported in other studies. The study provides strong evidence for greater regression among women who have vaginal deliveries. Careful work-up is recommended postpartum for this group of women in order to rule out persistent CIN 3 or invasive disease.

Purpose The aim was to develop and update a guideline which would improve the quality of care offered to women with gestational and non-gestational trophoblastic disease, a group of diseases characterized by their rarity and biological heterogeneity. Methods In accordance with the method used to compile S2k-guidelines, the guideline authors carried out a search of the literature (MEDLINE) for the period 1/2020 to 12/2021 and evaluated the recent literature. No key questions were formulated. No structured literature search with methodical evaluation and assessment of the level of evidence was carried out. The text of the precursor version of the guideline from 2019 was updated based on the most recent literature, and new statements and recommendations were drafted. Recommendations The updated guideline contains recommendations for the diagnosis and therapy of women with hydatidiform mole (partial and complete moles), gestational trophoblastic neoplasia after pregnancy or without prior pregnancy, persistent trophoblastic disease after molar pregnancy, invasive moles, choriocarcinoma, placental site nodules, placental site trophoblastic tumor, hyperplasia at the implantation site und epithelioid trophoblastic tumor. Separate chapters cover the determination and assessment of human chorionic gonadotropin (hCG), histopathological evaluation of specimens, and the appropriate molecular pathological and immunohistochemical diagnostic procedures. Separate chapters on immunotherapy, surgical therapy, multiple pregnancies with simultaneous trophoblastic disease, and pregnancy after trophoblastic disease were formulated, and the corresponding recommendations agreed upon.

Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG). Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or – if evidence was lacking – on a consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which took account of more recently published literature and the appraisal of the new evidence. Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Purpose Detection of SARS-CoV-2-infected pregnant women admitted to maternity units during a pandemic is crucial. In addition to the fact that pregnancy is a risk factor for severe COVID-19 and that medical surveillance has to be adjusted in infected women and their offspring, knowledge about infection status can provide the opportunity to protect other patients and healthcare workers against virus transmission. The aim of this prospective observational study was to determine the prevalence of SARS-CoV-2 infection among pregnant women in the hospital setting. Material and Methods All eligible pregnant women admitted to the nine participating hospitals in Franconia, Germany, from 2 June 2020 to 24 January 2021 were included. COVID-19-related symptoms, secondary diseases and pregnancy abnormalities were documented. SARS-CoV-2 RNA was detected by RT-PCR from nasopharyngeal swabs. The prevalence of acute SARS-CoV-2 infection was estimated by correcting the positive rate using the Rogan–Gladen method. The risk of infection for healthcare workers during delivery was estimated using a risk calculator. Results Of 2414 recruited pregnant women, six were newly diagnosed RT-PCR positive for SARS-CoV-2, which yielded a prevalence of SARS-CoV-2 infection of 0.26% (95% CI, 0.10 – 0.57%). Combining active room ventilation and wearing FFP2 masks showed an estimated reduction of risk of infection for healthcare workers in the delivery room to Conclusions The prevalence of newly diagnosed SARS-CoV-2 infection during pregnancy in this study is low. Nevertheless, a systematic screening in maternity units during pandemic situations is important to adjust hygienic and medical management. An adequate hygienic setting can minimise the calculated infection risk for medical healthcare workers during patientsʼ labour.

Fertility tracking devices offer women direct-to-user information about their fertility. The objective of this study is to understand how a fertility tracking device algorithm adjusts to changes of the individual menstrual cycle and under different conditions.A retrospective analysis was conducted on a cohort of women who were using the device between January 2004 and November 2014. Available temperature and menstruation inputs were processed through the Daysy 1.0.7 firmware to determine fertility outputs. Sensitivity analyses on temperature noise, skipped measurements, and various characteristics were conducted.A cohort of 5328 women from Germany and Switzerland contributed 107,020 cycles. Mean age of the sample was 30.77 [SD 5.1] years, with a BMI of 22.07 kg/m^2 [SD 2.4]. The mean cycle length reported was 29.54 [SD 3.0] days. The majority of women were using the device 80-100% of the time during the cycle (53.1%). For this subset of women, the fertility device identified on average 41.4% [SD 6.4] possibly fertile (red) days, 42.4% [SD 8.7] infertile (green) days and 15.9% [SD 7.3] yellow days. The number of infertile (green) days decreases proportionally to the number of measured days, whereas the number of undefined (yellow) days increases.Overall, these results showed that the fertility tracker algorithm was able to distinguish biphasic cycles and provide personalised fertility statuses for users based on daily basal body temperature readings and menstruation data. We identified a direct linear relationship between the number of measurements and output of the fertility tracker.

Purpose Colposcopy-guided punch biopsy is a cornerstone method for diagnosing vulvar diseases. The aim of this study was to evaluate the concordance rate of clinical findings in vulvar diseases during examinations, in comparison with colposcopy-directed punch biopsy. We also developed a new classification to simplify the categorization of vulvoscopic findings. Methods The concordance rate of the clinical findings was compared with the final histology results from punch biopsies. The data were collected between January 2014 and May 2017 at the Erlangen University Hospital. Results A total of 482 colposcopy-directed punch biopsies of the vulva were obtained in 420 women. The overall concordance rate of the clinical findings in comparison with the histological vulvar punch-biopsy findings was 53.9% for all entities — benign lesions, lichen, low- and high-grade squamous intraepithelial lesions (LSIL/HSILs), and vulvar carcinoma. The concordance rate for detecting LSILs was 64.3% (45/70). The concordance rate for detecting HSILs was 62.3% and for Vulvar carcinoma 65.2%. Conclusions Punch biopsy of suspicious lesions continues to be a cornerstone in diagnosing HSILs and carcinoma of the vulva. Careful work-up of the vulva is recommended when patients have symptoms such as pruritus or pain. The new classification is more specific for diagnosing lesions in the vulva.

Die Operation stellt die Therapie der Wahl beim fruhen Zervixkarzinom (FIGO IA1 bis FIGO IIa; gemas Federation Internationale de Gynecologie et d’Obstetrique) dar. Abhangig vom Alter der Patientin und der Tumorausbreitung ist das Ausmas der operativen Therapie fur die Patientin, insbesondere bei Wunsch nach Fertilitatserhalt, festzulegen. In letzter Zeit rucken zur Senkung der Mortalitat und Morbiditat zunehmend weniger radikale operative Verfahren und Konzepte zur Sentinellymphonodektomie in den Fokus. Kontroversen ergeben sich aktuell im Rahmen neuer Studien bezuglich der Wahl des operativen Zugangswegs. Der Beitrag stellt eine Ubersichtsarbeit zur operativen Therapie des Zervixkarzinoms dar. Es wird eine Ubersicht uber die aktuelle Studienlage und Literatur gegeben unter Einbeziehung der aktuell geltenden deutschen S3-Leitlinie zum Zervixkarzinom. Bei der Behandlung des lokal begrenzten Zervixkarzinoms (≤FIGO IIa) steht die operative Therapie im Vordergrund. In aktuellen Studien wie SHAPE wird untersucht, ob weniger radikale operative Verfahren ausreichend onkologische Sicherheit bieten konnen. Ein fertilitatserhaltendes Vorgehen ist je nach Vorliegen von Risikofaktoren bis zum Stadium IB1 moglich. Nach Veroffentlichung der Ergebnisse der LACC-Studie mit erhohter Rezidiv- und Mortalitatsrate beim laparoskopischen Vorgehen gegenuber der Laparotomie ist ein minimal-invasives Vorgehen mit den Patientinnen im Vorfeld unter Hinweis auf die Datenlage kritisch zu diskutieren. Die Therapie des Zervixkarzinoms sollte stadiengerecht erfolgen. Dabei ist die operative Therapie die Domane beim fruhen Zervixkarzinom. Auch weniger radikale Verfahren scheinen zunehmend ausreichend onkologische Sicherheit zu bieten.

The COVID-19 global pandemic has led to the death of millions around the world and impacted the overall health of many people. In this article we aim to compare reproductive health indicators in the first 6 months of 2020 to the prior year, as well as explore stress and quality of life during this time.This retrospective observational study examined the menstrual cycles of 1159 women who were using a fertility tracking device to record their menstrual cycle and BBT data. We utilised a supplemental mobile application to administer a supplemental survey to collect data on stress and quality of life. Descriptive analyses were conducted withStudy participants from 15 countries contributed to a total of 13,194 cycles. 23.1% (268/1159) responded to the survey focussed on assessing psychosocial distress. 44.4% (119/268) of the study participants reported that they had noticed a change in their menstrual cycle, temperature curve, or menstruation in the past 12 months. Cycle analysis found the average cycle length and pre-ovulation phase length was longer in the first 6 months of 2019, while the average days of menstruation was slightly longer in 2020.Our findings indicate that menstrual cycle indicators changed only slightly in the first 6 months of 2020 but were still statistically significant. We were also able to understand that these study participants had some level of awareness of changes to their menstrual health.

Simple Summary In node-positive vulvar squamous cell cancer, questions of when and how to perform pelvic lymphadenectomy (LAE) as well as the optimal extent of pelvic treatment in general have been surrounded by considerable controversy. In Germany, systematic pelvic LAE is currently recommended as a staging procedure in patients at risk for pelvic nodal involvement in order to prevent morbidity caused by pelvic radiotherapy (RT) in patients without histologically-confirmed pelvic involvement. However, the population at risk for pelvic metastases remains insufficiently described, resulting in the potential overtreatment of a considerable proportion of patients with groin-positive disease. This applies to the indication to perform surgical staging but also to adjuvant RT of the pelvis without previous pelvic staging. Our study aims to describe the risk for pelvic lymph node metastasis with regard to positive groin nodes and to clarify the indication criteria for pelvic treatment in node-positive vulvar cancer. Abstract The need for pelvic treatment in patients with node-positive vulvar cancer (VSCC) and the value of pelvic lymphadenectomy (LAE) as a staging procedure to plan adjuvant radiotherapy (RT) is controversial. In this retrospective, multicenter analysis, 306 patients with primary node-positive VSCC treated at 33 gynecologic oncology centers in Germany between 2017 and 2019 were analyzed. All patients received surgical staging of the groins; nodal status was as follows: 23.9% (73/306) pN1a, 23.5% (72/306) pN1b, 20.4% (62/306) pN2a/b, and 31.9% (97/306) pN2c/pN3. A total of 35.6% (109/306) received pelvic LAE; pelvic nodal involvement was observed in 18.5%. None of the patients with nodal status pN1a or pN1b and pelvic LAE showed pelvic nodal involvement. Taking only patients with nodal status ≥pN2a into account, the rate of pelvic involvement was 25%. In total, adjuvant RT was applied in 64.4% (197/306). Only half of the pelvic node-positive (N+) patients received adjuvant RT to the pelvis (50%, 10/20 patients); 41.9% (122/291 patients) experienced recurrent disease or died. In patients with histologically-confirmed pelvic metastases after LAE, distant recurrences were most frequently observed (7/20 recurrences). Conclusions: A relevant risk regarding pelvic nodal involvement was observed from nodal status pN2a and higher. Our data support the omission of pelvic treatment in patients with nodal status pN1a and pN1b.

The current cervical cancer screening program in Germany recommends that the results showing suspected HPV infection should be further examined in specialized colposcopy units. This study aimed to correlate externally documented Pap smear results with in-house colposcopy-guided Pap cytology results and compare colposcopy-guided biopsy and postoperative histopathology results. Clinical data were analyzed from 3627 examinations in 2844 patients who visited a university certified dysplasia unit from 2014 to 2017; 2212 patients underwent complete assessments, including Pap smear, colposcopy, HPV testing, colposcopy-guided biopsy, and/or surgery. The results were analyzed descriptively. External and in-house Pap results were consistent in 1054 ofthe 2212 patients (47.65%). Referral cytology showed a higher grade than in-house in 456 (20.61%) and a lower grade in 702 (31.74%). Using the histopathological findings as the gold standard, overdiagnosis in the referral cytology was noted in 180 patients (13.19%), underdiagnosis in 263 (19.27%), and concordant findings in 922 (67.55%). For in-house cytology, overdiagnosis was found in 133 patients (10.74%), underdiagnosis in 192 (15.51%), and accurate diagnosis with congruent cytology and histopathology findings in 913 (73.75%). The rate of detection of cervical abnormalities differs significantly depending on whether the examination is performed routinely or in specialized units. Colposcopy-guided Pap smears correlate significantly better with histology than referral cytology results without colposcopic guidance. More severe lesions were also detected more accurately.

BACKGROUND Approximately 4380 cases of cervical carcinoma were diagnosed in Germany in 2016. In women who had not participated in early detection programs, cervical carcinoma was usually already in an advanced stage at the time of diagnosis. Certified structures for care in conformity with the existing guidelines are available. METHODS The new German clinical practice guideline was revised with the participation of 50 medical societies under the expert guidance of the Guideline Program in Oncology, which includes the German Association of the Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). A systematic literature review was conducted. Systematic reviews, meta-analyses, and randomized controlled trials (RCTs) were considered. RESULTS The histologic tumor stage and lymph-node stage are essential determinants of the treatment strategy. The main innovation regarding surgical treatment is the revival of open hysterectomy (overall survival [minimally invasive vs open hysterectomy]: 94.04% vs 99.4%; hazard ratio [HR]: 6.00; 95% confidence interval [1.77; 20.30]). In addition, for tumors measuring 2 cm or less, sentinel node biopsy is recommended rather than radical pelvic lymphadenectomy. MRI-guided brachytherapy is an obligatory component of radiochemotherapy (overall survival [radiochemotherapy with vs without brachytherapy]: 58.2% vs 46.2%, p

In 2021, the 2015 German consensus guideline for the diagnosis and treatment of uterine cervical carcinoma was updated. The present article summarises the new recommendations for pathologists: the incorporation of the International Endocervical Adenocarcinoma Classification (IECC), which morphologically separates HPV-associated and non-HPV-associated adenocarcinomas, as well as the reporting of the prognostic relevant growth pattern of the adenocarcinoma of the endocervical subtype (Silva pattern). Histologically, multifocality has been defined as the presence of clearly invasive foci with a minimum distance between each focus of 0.2 cm. Because of its intratumoural heterogeneity, all carcinomas ≤ 2 cm in their largest dimension should be processed completely, and tumours 2 cm should be processed with one block per centimetre of their greatest dimension. In cases of (radical) trachelectomy/hysterectomy, the distal vaginal resection margin and all parametrial tissue should be processed completely. Sentinel lymph nodes have to be processed completely by lamellation along its long axis in 0.2 cm intervals. Immunohistochemical ultrastaging is mandatory. Staging should be performed using the 2009 FIGO classification and 2017 TNM classification. Reporting the revised 2018 FIGO classification is optional. To date, molecular markers have not been relevant for prognostication and treatment decision making.Im Jahr 2015 wurde die S3-Leitlinie für Diagnostik und Therapie des Zervixkarzinoms erstellt, die 2021 in ihrer revidierten Fassung vorliegt. Neu für die Pathologie sind die Aufnahme der International Endocervical Adenocarcinoma Classification (IECC), die zwischen HPV-assoziierten und non-HPV-assoziierten Karzinomen unterschiedet, sowie des prognostisch relevanten morphologischen Wachstumsmusters bei (HPV-assoziierten) Adenokarzinomen (sog. Silva-Pattern). Die Multifokalität beim mikroinvasiven Zervixkarzinom ist nun definiert als der Nachweis voneinander histologisch klar separierter invasiver Foci mit einem minimalen Abstand von 0,2 cm. Aufgrund einer möglichen intratumoralen Heterogenität sollen Zervixkarzinome ≤ 2 cm vollständig und Tumoren 2 cm mit einem Block pro Zentimeter größter Ausdehnung eingebettet werden. Bei der (radikalen) Trachelektomie/Hysterektomie sollen der vaginale Resektionsrand und das parametrane Gewebe vollständig eingebettet werden. Neu ist die Empfehlung zur Aufarbeitung von Sentinellymphknoten. Diese sollen entlang ihrer Längsachse in 0,2 cm Abstand lamelliert, vollständig eingebettet und mittels Ultrastaging aufgearbeitet werden. Die FIGO-Klassifikation von 2009 bzw. TNM-Kategorisierung von 2017 wird beibehalten, die Angabe der FIGO-Klassifikation 2018/19 ist optional. Molekulare Marker spielen derzeit noch keine relevante Rolle in der Prognose und zum Therapieentscheid.

ZusammenfassungIn den letzten Jahren haben sich Diagnostik und Therapie im Bereich der gynäkologischen Onkologie und Senologie stetig weiterentwickelt. Dennoch ist das Versterben an einer Krebserkrankung in den hoch entwickelten Ländern eine der häufigsten Todesursachen der Frau 1. Maßnahmen zur Primärprävention sind daher von hoher Bedeutung, um die Morbidität und Mortalität von Krebserkrankungen zu senken.

Bei vielen Organentitaten ist das neoadjuvante Konzept mittlerweile etablierter Bestandteil der Therapie. Die neoadjuvante Therapie scheint auch in speziellen Situationen fur Zervixkarzinompatientinnen interessant. Dieser Artikel soll einen Uberblick uber die aktuell diskutierten Einsatzgebiete in der Neoadjuvanz beim Zervixkarzinom darlegen, die verschiedenen Optionen werden besprochen. Als Grundlage fur diesen Artikel dient die S3-Leitlinie Diagnostik, Therapie und Nachsorge der Patientin mit Zervixkarzinom AWMF(Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften)-Registernummer 032/033OL in der Version von 2014. Diese wurde durch die Literatur zur Update-Recherche der Neufassung der Leitlinie erweitert. Die NACT(neoadjuvante Chemotherapie)-Ansprechrate liegt bei 84 %, das progressionsfreie Uberleben (PFS) uber 5 Jahre und das Gesamtuberleben (OS) betragen 61,9 und 72,8 %. Das Ansprechen auf eine NACT korreliert mit einem besseren Langzeituberleben. In einer Cochrane-Analyse von 2012 wurde gezeigt, dass eine neoadjuvante Chemotherapie vor geplanter Operation zu einer Verbesserung des PFS (HR [Hazard Ratio] 0,75, 95 %-KI [Konfidenzintervall] 0,61–0,93, p = 0,008) und des Gesamtuberlebens (HR 0,77, 95 %-KI 0,62–0,96, p = 0,02) fuhrt. Unter Berucksichtigung des Random-Effekt-Modells war der Effekt aber nicht mehr signifikant (OR [Odds Ratio] 0,60, 95 %-KI 0,32–1,12, p = 0,11). Bei makroinvasiven Karzinomen in der Schwangerschaft vor einer moglichen Entbindung ist die NACT fester Bestandteil der Therapie. Die Datenlage zum Einsatz der neoadjuvanten Therapie beim Zervixkarzinom ist unklar. Die neoadjuvante Therapie ist aktuell kein Standard in der Behandlung des Zervixkarzinoms. Ungeklart ist auch die Rolle des operativen Stagings und positiver Lymphknoten nach der neoadjuvanten Therapie. In verschiedenen Metaanalysen konnte gezeigt werden, dass die neoadjuvante Therapie das PFS und das OS verbessert. Dies gilt insbesondere fur Frauen, die auf die neoadjuvante Therapie angesprochen haben.

Cervical cancer is caused by persistent infection with high-risk human papillomavirus (hrHPV). Cytology-based national screening programs have reduced the incidence and mortality of cervical cancer. Different hrHPV subtypes have different carcinogenic potentials. This study evaluated the distribution of different types of hrHPV relative to age in cervical cancer and its precursor lesions.HPV testing was performed between November 2018 and February 2020 using the Abbott RealTime high-risk HPV assay on an Abbott m2000sp instrument. This assay separately detects HPV-16, HPV-18, and a pool of 12 additional hrHPV types (HPV-31, -33, -35, -39, -45, -51, -52, -56, -58, -59, -66, and -68).The study included 652 women with HPV samples and biopsies of the cervix or histology samples obtained during surgery. In all, 30.8% (95% CI, 27.3-34.6%) were HPV-negative. Among HPV-positive women, HPV-16, HPV-18, and "HPV other" types were found in 33.5, 4.4, and 49.4%, respectively. Cervical intraepithelial neoplasia (CIN) 3/high-grade squamous intraepithelial lesions (HSILs) in women ≤ 34 years were positive for HPV-16 in 54.5% of cases and in those ≥ 35 years in 45.4% of cases. Among women with cervical cancer, 75.8% were infected with HPV-16 or had coinfection with HPV-16 and "HPV other".HPV-16 is the most common type of hrHPV in HSIL + lesions. It is more common in women diagnosed with CIN 3/HSIL who are aged ≤ 35 and is decreasing with age. Therefore, women age ≥ 35 with persistent infection with this type of hrHPV need careful surveillance, as they are at high risk of progression to cervical cancer.

Purpose This is an official guideline, published and coordinated by the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG) and the German Society for Gynecology and Obstetrics (DGGG). Vaginal cancers are rare tumors, which is why there is very little evidence on these tumors. Knowledge about the optimal clinical management is limited. This first German S2k guideline on vaginal cancer has aimed to compile the most current expert knowledge and offer new recommendations on the appropriate treatment as well as providing pointers about individually adapted therapies with lower morbidity rates than were previously generally available. The purpose of this guideline is also to set up a register to record data on treatment data and the course of disease as a means of obtaining evidence in future. Methods The present S2k guideline was developed by members of the Vulvar und Vaginal Tumors Commission of the AGO in an independently moderated, structured, formal consensus process and the contents were agreed with the mandate holders of the participating scientific societies and organizations. Recommendations To optimize the daily care of patients with vaginal cancer: 1. Monitor the spread pattern; 2. Follow the step-by-step diagnostic workup based on initial stage at detection; 3. As part of individualized clinical therapeutic management of vaginal cancer, follow the sentinel lymph node protocol described here, where possible; 4. Participate in the register study on vaginal cancer.

Malignancies of the vagina are rare, but colposcopy-directed biopsies play a major role in detecting vaginal intraepithelial lesions. Data of accuracy in detecting neoplasia of the vagina are very rare compared to accuracy in detecting cervical neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with clinical findings of the examiner. The accuracy of colposcopy-directed biopsy was compared with the clinical finding in relation to the patient’s age and the examiner’s level of training. This was done in combination with PAP-smear, HPV-test results, and the history of other malignancies of the lower genital tract. The data were collected between January 2014 and February 2018 at the certified Dysplasia Unit of the University Hospital Erlangen. In total, 253 biopsies from 253 women from the vagina were obtained. The overall accuracy of biopsy in comparison with clinical finding was 52.17% for all entities—benign lesions, low-grade squamous intraepithelial lesions (LSILs), high-grade squamous intraepithelial lesions (HSILs), and vaginal carcinoma. The accuracy for detecting HSIL was 82.46% (47/57), with an underdiagnosis rate of 15.79% and an overdiagnosis rate of 1.79%. With a sensitivity of over 80%, colposcopy-directed biopsy plays an important role in detecting vaginal–HSIL. A highly experienced practitioner is increasing the sensitivity in detecting vaginal–HSIL. Careful examination is required in women with a history of HSIL of the lower genital tract or with simultaneous neoplasia because they are of greater risk of developing vaginal malignancies. The combination of careful clinical work up, PAP-smear, HPV-testing, and colposcopy-guided biopsy is crucial in detecting vaginal–HSIL.

A novel histopathological grading system based on tumour budding and cell nest size has recently been shown to outperform conventional (WHO-based) grading algorithms in several tumour entities such as lung, oral, and oesophageal squamous cell carcinoma (SCC) in terms of prognostic patient stratification. Here, we tested the prognostic value of this innovative grading approach in two completely independent cohorts of SCC of the uterine cervix. To improve morphology-based grading, we investigated tumour budding activity and cell nest size as well as several other histomorphological factors (e.g., keratinization, nuclear size, mitotic activity) in a test cohort (n = 125) and an independent validation cohort (n = 122) of cervical SCC. All parameters were correlated with clinicopathological factors and patient outcome. Small cell nest size and high tumour budding activity were strongly associated with a dismal patient prognosis (p < 0.001 for overall survival [OS], disease-specific survival, and disease-free survival; test cohort) in both cohorts of cervical SCC. A novel grading algorithm combining these two parameters proved to be a highly effective, stage-independent prognosticator in both cohorts (OS: p < 0.001, test cohort; p = 0.001, validation cohort). In the test cohort, multivariate statistical analysis of the novel grade revealed that the hazard ratio (HR) for OS was 2.3 for G2 and 5.1 for G3 tumours compared to G1 neoplasms (p = 0.010). In the validation cohort, HR for OS was 3.0 for G2 and 7.2 for G3 tumours (p = 0.012). In conclusion, our novel grading algorithm incorporating cell nest size and tumour budding allows strongly prognostic histopathological grading of cervical SCC superior to WHO-based grading. Therefore, our data can be regarded as a cross-organ validation of previous results demonstrated for oesophageal, lung, and oral SCC. We suggest this grading algorithm as an additional morphology-based parameter for the routine diagnostic assessment of this tumour entity.

Mit einer Inzidenz von 5,8/100 000 Frauen/Jahr ist das Vulvakarzinom das vierthäufigste Genitalkarzinom der Frau. Meist werden Vulvakarzinome in einem frühen Stadium diagnostiziert. Häufigstes Symptom ist der therapieresistente Pruritus, perineale Schmerzen und/oder beim Sitzen, Dysurie und Brennen. Bei der klinischen Inspektion sollte das komplette äußere Genitale mit Vagina, Perineum, Anus sowie die Zervix inspiziert werden. Liegt eine VIN1, LSIL (vulväre intraepitheliale Neoplasie Grad 1, low-grade squamous intraepithelial lesion) ohne Symptome vor, sind regelmäßige Kontrollen ausreichend. Bei symptomatischer LSIL, HPV-assoziierter VIN2 oder VIN3 (vulväre intraepitheliale Neoplasie Grad 2 oder 3, high-grade squamous intraepithelial lesion) kann eine Laserevaporisation erfolgen. Eine komplette Vulvektomie sollte nur bei multizentrischen Tumoren erfolgen. Eine systematische Lymphonodektomie ist ab Stadium T1b mit Infiltrationstiefe > 1 mm empfohlen. Eine adjuvante Radiotherapie der Primärtumorregion sollte bei non-in-sano-Situation durchgeführt werden, falls eine Nachresektion aus funktionellen Gründen oder Patientenwunsch nicht möglich ist. Eine lebenslange Nachsorge ist notwendig, denn jede dritte Patientin mit Vulvakarzinom erleidet ein Rezidiv. Als Therapie des Lokalrezidivs ohne Beteiligung von Anus, Urethra oder Lymphknoten sollte eine operative Resektion mit R0-Situation angestrebt werden.

The current cervical cancer screening program in Germany recommends that the results showing suspected HPV infection should be further examined in specialized colposcopy units. This study aimed to correlate externally documented Pap smear results with in-house colposcopy-guided Pap cytology results and compare colposcopy-guided biopsy and postoperative histopathology results.Clinical data were analyzed from 3627 examinations in 2844 patients who visited a university certified dysplasia unit from 2014 to 2017; 2212 patients underwent complete assessments, including Pap smear, colposcopy, HPV testing, colposcopy-guided biopsy, and/or surgery. The results were analyzed descriptively.External and in-house Pap results were consistent in 1054 ofthe 2212 patients (47.65%). Referral cytology showed a higher grade than in-house in 456 (20.61%) and a lower grade in 702 (31.74%). Using the histopathological findings as the gold standard, overdiagnosis in the referral cytology was noted in 180 patients (13.19%), underdiagnosis in 263 (19.27%), and concordant findings in 922 (67.55%). For in-house cytology, overdiagnosis was found in 133 patients (10.74%), underdiagnosis in 192 (15.51%), and accurate diagnosis with congruent cytology and histopathology findings in 913 (73.75%).The rate of detection of cervical abnormalities differs significantly depending on whether the examination is performed routinely or in specialized units. Colposcopy-guided Pap smears correlate significantly better with histology than referral cytology results without colposcopic guidance. More severe lesions were also detected more accurately.

Breast cancer risk is reduced by number of pregnancies and breastfeeding duration, however studies of breast changes during or after pregnancy are rare. Breast volume changes – although not linked to breast cancer risk – might be an interesting phenotype in this context for correlative studies, as changes of breast volume vary between pregnant women. Serum receptor activator of nuclear factor kappa B ligand (RANKL) and its antagonist osteoprotegerin (OPG) were measured prospectively before gestational week 12, and three-dimensional breast volume assessments were performed. A linear regression model including breast volume at the start of pregnancy, RANKL, OPG, and other factors was used to predict breast volume at term. The mean breast volume was 413 mL at gestational week 12, increasing by a mean of 99 mL up to gestational week 40. In addition to body mass index and breast volume at the beginning of pregnancy, RANKL and OPG appeared to influence breast volume with a mean increase by 32 mL (P = 0.04) and a mean reduction by 27 mL (P = 0.04), respectively. Linking the RANKL/RANK/OPG pathway with breast volume changes supports further studies aiming at analysing breast changes during pregnancy with regard to breast cancer risk.

Durch die Einfuhrung der Triple-Incision-Technik, der Sentinelnode-Biopsie und einer Zunahme der Diagnosestellung fur Malignome der Vulva in fruheren Stadien sind lokale kleinere Eingriffe haufiger und ausgedehnte radikale Eingriffe mit komplizierten plastischen Deckungsverfahren seltener geworden. Die Vulvachirurgie erfordert detaillierte Kenntnisse in rekonstruktiven Verfahren im Hinblick auf Lebensqualitat, Funktionalitat und onkologischer Sicherheit. Wundheilungsstorungen sind im urogenitalen Bereich keine Seltenheit und erfordern Erfahrung in der Auswahl der rekonstruktiven Technik und im Komplikationsmanagement. Eingriffe an der Vulva beeintrachtigen die Lebensqualitat meist nachhaltig, psychisch wie auch physisch, sodass alleine Sitzen fur die Patientinnen zum dauerhaften Problem werden kann. Das stadiengerechte, therapeutische Procedere beim Vorliegen eines Vulvakarzinoms wird ausfuhrlich beschrieben und verschiedene operative Verfahren zur Defektdeckung vorgestellt.

Die Heterogenitat der Diagnostik und der Therapie des Zervixkarzinoms bei kaum sinkender Morbiditat und Mortalitat machte ein Upgrade der bestehenden S2k-Leitlinie von 2008 auf S3-Niveau notwendig. Dies fuhrte zur seit 2014 gultigen S3-Leitlinie „Diagnostik, Therapie und Nachsorge der Patientin mit Zervixkarzinom“ (AWMF-Registernummer: 032-033OL). Die vorliegende Ubersichtsarbeit stellt den aktuellen Therapiestandard des Zervixkarzinoms dar und geht dabei im Speziellen auf die medikamentose Therapie ein. Es wird auserdem Stellung zur Diagnostik genommen, die letztlich zur Therapieentscheidung fuhrt. Auf Basis der aufwendigen Evidenzaufarbeitung und der Empfehlungen der S3-Leitlinie werden die aktuellen Therapiealgorithmen dargelegt und diskutiert. Die Therapie des Zervixkarzinoms erfolgt in den fruhen Stadien zumeist operativ. Ab Stadium FIGO IIB besteht die Indikation zur simultanen cisplatinhaltigen Radiochemotherapie. Beim nichtoperablen Rezidiv oder in der metastasierten Situation gibt es palliative Chemotherapieoptionen. Seit 2014 ist auch erstmals die Hinzunahme eines zielgerichteten Therapiekonzepts mit Bevacizumab moglich. Die Behandlung von Zervixkarzinomen hat sich in den letzten Jahren deutlich weiterentwickelt. Die Therapieoptionen sind vielfaltig, sie werden individuell und stadienadaptiert eingesetzt. Die Entscheidung uber die Therapiemodalitat erfolgt interdisziplinar in der Tumorkonferenz. Sie ist individuell angepasst und sollte gemeinsam mit der Patientin getroffen werden. Berucksichtigt werden mussen der Allgemeinzustand und die Lebenssituation der Patientin sowie Erkrankungsstadium, Risikofaktoren und das unterschiedliche Nebenwirkungsprofil der Therapien. Ziel ist eine moglichst geringe Beeinflussung der Lebensqualitat bei maximalem Uberleben.

Colposcopy-directed biopsy is a cornerstone method for diagnosing cervical intraepithelial neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with definitive surgery. The accuracy of colposcopy-directed biopsy was compared with the final histology in relation to different types of transformation zone (TZ), the patient’s age, and the examiner’s level of training. The overall accuracy of biopsy in comparison with definitive surgery was 71.9% for all entities—benign lesions, low-grade squamous intraepithelial lesions, high-grade squamous intraepithelial lesions (HSILs), and cervical carcinoma—with an underdiagnosis rate of 11.8% and an overdiagnosis rate of 16.5%. The accuracy for detecting HSIL was 88% (401/455), with an underdiagnosis rate of 10.5% and overdiagnosis rate of 1.3%. The accuracy rates for detecting HSIL in women with TZ 1, TZ 2, or TZ 3 were 92.2, 90.5, and 76.5%, respectively. The accuracy rates for detecting HSIL in the different age groups were 93.1% (age 0–34), 83.6% (age 34–55), and 80% (age 55 or older). A combination of the colposcopic findings, cytology, human papillomavirus testing, and colposcopy-directed biopsy is necessary for the correct diagnosis of HSIL. The accuracy rate depends on the TZ and the patient’s age. The examiner’s level of training does not have any substantial influence on the accuracy.

Background Daysy is a fertility monitor that uses the fertility awareness method by tracking and analyzing the individual menstrual cycle. In addition, Daysy can be connected to the application DaysyView to transfer stored personal data from Daysy to a smartphone or tablet (IOS, Android). This combination is interesting because as it is shown in various studies, the use of apps is increasing patients´ focus on their disease or their health behavior. The aim of this study was to investigate if by the additional use of an App and thereby improved usability of the medical device, it is possible to enhance the typical-use related as well as the method-related pregnancy rates. Result In the resultant group of 125 women (2076 cycles in total), 2 women indicated that they had been unintentionally pregnant during the use of the device, giving a typical-use related Pearl-Index of 1.3. Counting only the pregnancies which occurred as a result of unprotected intercourse during the infertile (green) phase, we found 1 pregnancy, giving a method-related Pearl-Index of 0.6. Calculating the pregnancy rate resulting from continuous use and unprotected intercourse exclusively on green days, gives a perfect-use Pearl-Index of 0.8. Conclusion It seems that combining a specific biosensor-embedded device (Daysy), which gives the method a very high repeatable accuracy, and a mobile application (DaysyView) which leads to higher user engagement, results in higher overall usability of the method. Electronic supplementary material The online version of this article (10.1186/s12978-018-0479-6) contains supplementary material, which is available to authorized users.

Background In March 2018, Dr. Martin C. Koch and colleagues published an analysis purporting to measure the effectiveness of the Daysy device and DaysyView app for the prevention of unintended pregnancy. Unfortunately, the analysis was flawed in multiple ways which render the estimates unreliable. Unreliable estimates of contraceptive effectiveness can endanger public health. Main body This commentary details multiple concerns pertaining to the collection and analysis of data in Koch et al. 2018. A key concern pertains to the inappropriate exclusion of all women with fewer than 13 cycles of use from the Pearl Index calculations, which has no basis in standard effectiveness calculations. Multiple additional methodological concerns, as well as prior attempts to directly convey concerns to the manufacturer regarding marketing materials based on prior inaccurate analyses, are also discussed. Conclusion The Koch et al. 2018 publication produced unreliable estimates of contraceptive effectiveness for the Daysy device and DaysyView app, which are likely substantially higher than the actual contraceptive effectiveness of the device and app. Those estimates are being used in marketing materials which may inappropriately inflate consumer confidence and leave consumers more vulnerable than expected to the risk of unintended pregnancy. Prior attempts to directly convey concerns to the manufacturer of this device were unsuccessful in preventing publication of subsequent inaccurate analyses. To protect public health, concerns with this analysis should be documented in the published literature, the Koch et al. 2018 analysis should be retracted, and marketing materials on contraceptive effectiveness should be subjected to appropriate oversight.

Aim: Effective pain management during labour is important because pain affects the birth experience. Epidural analgesia is effective but often it may not be possible; however, inhaled analgesia offers another option. Use of inhaled nitrous oxide and oxygen for pain management in labour is well established in obstetrics but is still not used much in Germany. This study aimed to investigate the acceptance of the inhaled analgesia of inhaled nitrous oxide and oxygen by midwives and pregnant women during labour. Material and Methods: In this observational study carried out between April and September 2013, a total of 66 pregnant women received inhaled nitrous oxide and oxygen during labour on request and after prior assessment of suitability. After the birth, all of the women and the responsible midwives were interviewed about their experience and satisfaction with the inhaled analgesia. Results: A statistically significant reduction of pain was achieved with nitrous oxide and oxygen. The inhaled analgesia was mostly used by women who refused epidural analgesia. The likelihood of using inhaled nitrous oxide and oxygen again was reported as higher for patients who tolerated it well (p = 0.0129) and used it in the second stage of labour (p = 0.0003) and when bearing down (p = 0.0008). Conclusion: Inhaled nitrous oxide and oxygen is an effective method for pain management during labour and is accepted well by women in labour and by midwives.

HPV (humanes Papillomavirus) ist ein Hauptrisikofaktor fur die Entstehung des Vulva- und Vaginalkarzinoms. Eine Zunahme der HPV-Infektionen konnte mit einer Zunahme beider Karzinomentitaten korrelieren. Eine Impfung gegen HPV ist seit einigen Jahren verfugbar. Ziel der Recherche war es, eine Ubersicht uber die aktuelle Datenlage bezuglich epidemiologischer und atiologischer Faktoren des Vulva- und Vaginalkarzinoms zu prasentieren. Es wurde eine Recherche der vorhandenen Literatur in etablierten medizinischen Datenbanken (Medline, Cochrane Database) sowie ein Review der vorhandenen epidemiologischen und atiologischen Daten durchgefuhrt. Innerhalb der letzten Jahrzehnte kam es zu einer Zunahme der HPV-Infektionen bei jungen Frauen und dadurch zu einer steigenden Inzidenz der HPV-induzierten Karzinome von Vulva und Vagina. Dies betraf die Gesamtpopulation, jedoch insbesondere auch jungere Frauen. Das Wissen um die Epidemiologie und die Atiologie des Vulva- und Vaginalkarzinoms ist nicht nur wichtig fur die Therapieentscheidung und die Therapieart, sondern auch von Bedeutung hinsichtlich des postoperativen Managements der Patientin im Sinne einer Risikostratifizierung. Eine besondere Bedeutung haben v. a. die rezidiv-gefahrdeten Patientinnen mit einem HPV-negativen Vulvakarzinom oder einer differenzierten VIN (d-VIN). Das Wissen um die Zunahme der HPV-Infektionen und die dadurch steigende Inzidenz der HPV-induzierten Vulva- und Vaginalkarzinome sollte aktiv in die Fruherkennung durch eine obligate und genaue Inspektion von Vulva und Vagina mit einbezogen werden. Inwieweit die HPV-Impfung Einfluss auf epidemiologische Grosen wie die Inzidenz und Pravalenz der Vulva- und Vaginalkarzinome nehmen wird bleibt in den kommenden Jahren abzuwarten. Dies ist stark abhangig von der Entwicklung der Durchimpfungsrate der Bevolkerung auch in Deutschland.

Purpose: This is an official guideline, published and coordinated by the Arbeitsgemeinschaft Gynakologische Onkologie (AGO, Study Group for Gynecologic Oncology) of the Deutsche Krebsgesellschaft (DKG, German Cancer Society) and the Deutsche Gesellschaft fur Gynakologie und Geburtshilfe (DGGG, German Society for Gynecology and Obstetrics). The number of cases with vulvar cancer is on the rise, but because of the former rarity of this condition and the resulting lack of literature with a high level of evidence, in many areas knowledge of the optimal clinical management still lags behind what would be required. This updated guideline aims to disseminate the most recent recommendations, which are much clearer and more individualized, and is intended to create a basis for the assessment and improvement of quality care in hospitals. Methods: This S2k guideline was drafted by members of the AGO Committee on Vulvar and Vaginal Tumors; it was developed and formally completed in accordance with the structured consensus process of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). Recommendations: 1. The incidence of disease must be taken into consideration. 2. The diagnostic pathway, which is determined by the initial findings, must be followed. 3. The clinical and therapeutic management of vulvar cancer must be done on an individual basis and depends on the stage of disease. 4. The indications for sentinel lymph node biopsy must be evaluated very carefully. 5. Follow-up and treatment for recurrence must be adapted to the individual case.

The present study was aimed at clarifying if use of a rapid human papillomavirus type 16 L1-specific antibody test could be used to improve clinical management of high-risk HPV-positive low-grade squamous intraepithelial lesion (LSIL)/high-grade squamous intraepithelial lesion (HSIL).The study was nested within a prospective study of 801 patients with early dysplastic high-risk HPV-positive lesions to examine the prognostic significance of HPV-L1 protein detection. Serum samples of 87 patients were tested with a rapid HPV16-L1-specific antibody test. The results were correlated with the clinical outcome during 66 months of follow-up.A combined analysis of the 22 antibody-positive women showed that 17 were also L1 protein-positive, and 5 were L1 capsid protein-negative. An HPV-specific immune competence strongly correlates with clinical remission of low-grade squamous intraepithelial lesion (76.6%). For L1 antigen and HPV16-L1 antibody double-positive women, the risk of progression to cervical intraepithelial neoplasia grade 3 was low (5.8%).The rapid anti-HPV16-L1 test could be a promising tool to improve risk assessment and appropriate clinical management of high-risk HPV-positive early dysplastic lesions.

Die Uberaktivierung des vaskularen endothelialen Wachstumsfaktors (VEGF) spielt beim invasiven Gebarmutterhalskrebs eine wichtige Rolle. Der humanisierte Anti-VEGF-Antikorper Bevacizumab ist als Einzelsubstanz bei vorbehandelten Patientinnen mit rezidiviertem Zervixkarzinom wirksam. Gilt das auch fur die Kombination mit der Chemotherapie?

Breast volume is a relevant measure for the prevention and prediction of diseases and for aesthetic surgery. This study evaluated a new technique to determine breast volume and compared measures using a three-dimensional (3D) body surface scanner and magnetic resonance imaging (MRI) scans, with the latter used as the standard method. Both MRI scans and body surface 3D scans were obtained from 22 women. For each method, breast volumes were assessed. The MRI calculations of the breast volumes were performed by a specially trained radiologist using analysis software. A textured 3D image was generated by a calibrated digital texture camera after breast surface data acquisition. The volume assessment of the 3D photography was calculated using a software package after manual outlining of the breast and automated projection of a dorsal limit. Linear regression was used to predict the MRI volume assessment with the 3D image volume assessment. The mean breast volume according to MRI volumetry was 442.8 ml on the left side and 471.8 ml on the right side. The mean breast volume using a 3D body surface volume assessment method was 273.8 ml (observer A) and 226.2 ml (observer B) on the left side and 284.4 ml (observer A) and 234.9 ml (observer B) on the right side. The use of linear regression models showed R 2 values of 0.59–0.77. The mean time for MRI recording and volume assessment was 68.0 ± 14.1 min for both sides and 11.6 ± 1.5 min for 3D recording and volume assessment. The 3D surface-based volume measurements are feasible in terms of time and can predict the MRI breast volume with sufficient accuracy. This might facilitate the broad use of such an assessment technique in a large-scale epidemiologic study using breast volume as a study aim. Additionally, further development of volume assessments could help to implement this technique in breast surgery procedures.

Die Diagnostik der zervikalen intraepithelialen Neoplasien (CIN) der Cervix uteri stützt sich derzeit auf die Zytologie, dem individuellen Erfahrungsschatz des Untersuchers in der Kolposkopie und letztlich auf die histologische Diagnostik. Ein von uns prototypisch entwickeltes System der Computer-assistierten Diagnose für die Kolposkopie erzielt bei einer automatischen Analyse von Bildbefunden eine höhere Sicherheit gegenüber der gängigen Diagnostik der Kolposkopie von 80 % (Sensitivität: 85 %, Spezifität: 75 %). Untersucht wurde in dieser Pilotstudie die Fragestellung ob ein solches CAD-System prinzipiell die Beurteilung des Untersuchers positiv unterstützen und damit die Gesamtdiagnostik verbessern kann. Im Rahmen einer Observerstudie wurden 24 digitalisierte kolposkopische Aufnahmen von Patientinnen der Dysplasiesprechstunde durch 21 Studienteilnehmer beurteilt. Unter den Studienteilnehmern waren 8 Experten mit einer kolposkopischen Erfahrung von mehr als 4 Jahren sowie 13 Nicht-Experten mit einer Erfahrung unter 4 Jahren. Alle Studienteilnehmer hatten im Rahmen eines Kolposkopiekurses die gleichen Grundlagen erworben bzw. aufgefrischt. Es wurde eine organisierte Beurteilung der Bilder ohne und mit in Anspruchnahme des CAD-Prototypen durchgeführt. Es zeigte sich eine höhere Varianz bei den Nicht-Experten im Gegensatz zu den Experten. Die Sicherheit bei der Befundung der Bilder zeigt eine Gesamtverbesserung nach Inanspruchnahme des CAD-Systems (Nicht-Experten: mittlere Sensitivität von 76 % auf 82 %, mittlere Spezifität von 62 % auf 65 %, Experten: mittlere Sensitivität von 73 % auf 79 %, mittlere Spezifität: 69 %). 85 % der Teilnehmer empfanden durch die Benutzung des CAD-System eine höhere Befundungssicherheit. 76 % der Teilnehmer meinten die Befundung schneller durchführen zu können. Das untersuchte CAD-System besitzt in seiner derzeitigen Entwicklungsstufe eine unterstützende Funktion in der weiterführenden Diagnostik der zervikalen intraepithelialen Neoplasien (CIN) und könnte potenziell zur Verbesserung der Befundung beitragen.