Malignant germ cell tumors of the ovary: a review of 41 cases and risk factors for recurrence

OBJECTIVE

To review the outcome of treatment in patients with malignant ovarian germ cell tumors and to define the risk factors for recurrence.

MATERIAL AND METHODS

Forty-one patients with malignant ovarian germ cell tumors were reviewed retrospectively. Survival time and survival rate were obtained. Risk factors such as stage, histological type, and type of operation were evaluated for reccurrence.

RESULTS

Twenty-three (56%) had dysgerminomas, eight (19.5%) had mixed germ cell tumors, three (7.3%) had yolk sac tumors, three (7.3%) had immature teratomas, two (4.8%) had squamous cell carcinoma arising from a mature teratoma, one (2.4%) had embryonal carcinoma and one choriocarcinoma. Most of the cases (73%) were in Stage I. Twenty-nine patients (70.7%) underwent conservative surgery and 12 patients (29.3%) had at least bilateral salpingo-oophorectomy. Thirty patients were operated on optimally with surgical staging and 11 suboptimally. Seven patients (17%) had recurrence after remission. The overall survival time was 187 +/- 8.43 months for all cases, 195 +/- 8.49 for dysgerminoma and 161 +/- 10.96 for non-dysgerminoma cases with a median follow-up time of 98.52 (8-204) months. Non-dysgerminoma histologic type, being operated on suboptimally and radically, and advanced tumor stage have been found to be risk factors for recurrence.

CONCLUSION

Regardless of histologic types and stages the prognosis of germ cell tumors are satisfactory with current therapeutic strategies.

Interactive neuromonitoring methods of cochlea and auditory nerve during induced hypoxia and nerve manipulation

Methods and instrumentation were developed to monitor cochlea and auditory function during surgery. The system allows real time assessment of the cochlear function during auditory nerve manipulation. A specially designed optic probe, placed on the round window (RW) niche, enables simultaneous acquisition of cochlear blood flow (CBF) and electrocochleogram (ECochG). We developed the acquisition paradigms, signal processing methods and implement them in a computational platform. The neuromonitoring system performs an automatic extraction and analysis of cochlear microphonics (CM), compound action potentials (CAP) and sura mating potential (SP). The system uses envelope detection filters to detect the amplitude of the CM. The CAP signal is processed with zero phase shift spectral filters, tuned to enhance the action potential onset, which is sometimes embedded within the sura mating potential. An automatic peak detection and tracking algorithm is then applied to extract latency and amplitude of CAPs. Long-term assessment of the monitoring system was performed during experimental animal surgeries. The system allowed detailed study of the dynamics of CM, CAP and CBF during nerve manipulation and compression.

Ovarian clear cell adenocarcinoma producing alpha-fetoprotein: case report

BACKGROUND

Alpha-fetoprotein (AFP) is a useful tumor marker for germ cell tumors of the ovary and is valuable for both diagnosis and follow-up. However, it is very rare for an epithelial ovarian carcinoma to secrete AFP.

CASE

We report a case of a 63-year-old woman with a ovarian clear cell carcinoma with serous component of less than 10%. Both histological components were producing AFP as demonstrated by immunohistochemistry. After surgery and chemotherapy, AFP decreased to normal range. The patient also had elevated CA-125 levels but the tumor was negative for CA-125 which suggested the increased CA-125 might have been due to the associated ascites.

CONCLUSION

Ovarian clear cell type carcinomas rarely secrete only AFP and it might be the single marker that could be used in follow-up.

Radiation-induced benign glandular cells in posthysterectomy smears: a cytomorphologic and clinical analysis

In this retrospective study, we aimed to investigate the frequency and cytomorphologic characteristics of benign glandular cells (BGCs) in hysterectomized individuals. We also discussed the possible effect of radiation therapy on these cells. We reviewed our cytopathology archive material through a 5.5-year period and found 1460 posthysterectomy vaginal smears. Of these, 508 smears were from patients who had undergone hysterectomy for a gynecological malignancy. Review of this vaginal cytology material revealed 17 posthysterectomy patients whose smears contained BGCs. We obtained detailed clinical information in 16 of these. In addition to routine Papanicolaou staining, mucicarmine stain was also used to demonstrate cytoplasmic mucin in some cases. All the patients had a history of gynecological malignancy and had radiation therapy. Glandular cells appeared singly or in rows and honeycomb groups and did not show cytologic atypia. We concluded that radiation might give rise to a metaplastic process in which basal cells of squamous epithelium of the vagina transform into glandular cells. Most probably this process is independent of radiation dosage and period and is irreversible. We also propose that the possibility of encountering glandular cells in posthysterectomy smears is higher than expected, if the mucin stains have been used for the microscopic examination.

Gabapentin: an alternative to the cyclooxygenase-2 inhibitors for perioperative pain management

The cyclooxygenase-2 inhibitor, rofecoxib, was a popular analgesic adjuvant for improving perioperative pain management. We designed this placebo-controlled study to test the hypothesis that gabapentin could produce similar reductions in postoperative pain and opioid analgesic usage, thereby improving the recovery process. One hundred patients undergoing abdominal hysterectomy procedures were randomly assigned to one of four treatment groups: 1) control group received placebo capsules and pills before and for 2 days after surgery, 2) rofecoxib group received 50 mg/d PO and placebo capsules before and after surgery and, 3) gabapentin group received 1.2 g/d PO and placebo pills before and after surgery, and 4) combination group received rofecoxib 50 mg/d and gabapentin 1.2 g/d PO before and after surgery. The anesthetic technique was standardized and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Postoperative pain scores were significantly reduced in all three analgesic treatment groups (versus control group). Compared with the control group, patient-controlled analgesia morphine usage was also significantly reduced in the 3 analgesic treatment groups at 1, 8, 24, and 30 h after surgery. Total PCA morphine usage was decreased by 43%, 24%, and 50% in groups 2, 3, and 4, respectively, compared with group 1. Oral analgesic consumption was also smaller in groups 2 and 4 when compared with the control group. The opioid-sparing effects of rofecoxib and gabapentin lead to a faster recovery of bowel function. Discharge eligibility scores in groups 2 and 4 were improved at 24 h when compared with group 1, and patient satisfaction with postoperative pain management was significantly higher at 24 h in all 3 analgesic treatment groups. At the 72 h follow-up, all of the patients in group 4 were completely satisfied with their pain management compared with only 32%, 64%, and 72% in groups 1, 2, and 3, respectively. Gabapentin (1.2 g/d PO) appears to be an acceptable alternative to rofecoxib (50 mg/d PO) for short-term use as an adjuvant to opioid analgesics in patients undergoing lower abdominal surgery.

Granulomatous villitis formed by inflammatory cells with maternal origin: a rare manifestation type of placental toxoplasmosis

We present a case of placental toxoplasmosis with granulomatous villitis. The patient was a 26-year-old gravida 1 female with the findings of intrauterine death at 16th week of gestation. The pregnancy was terminated. Pathological examination revealed an autolysed fetus and a placenta with necrotizing granulomas within the villous stroma. Encysted Toxoplasma gondii was rarely observed within the granulomas and serologic examination of the mother confirmed acute toxoplasmosis. A fluorocein in situ hybridization examination, using sex chromosome probes, revealed that the villous granulomas were formed by inflammatory cells, originated from the maternal immune system. In conclusion, T. gondii should be taken into consideration as a rare cause of placental granulomatous inflammation. To the best of our knowledge, this is the first case of granulomatous villitis due to toxoplasmosis, in which formation by maternal inflammatory cells has been demonstrated.

Identification of extracellular enzyme producing thermophilic bacilli from Balcova (Agamemnon) geothermal site by ITS rDNA RFLP

AIMS

Molecular characterization of extracellular enzyme producing thermophilic bacilli from Balcova geothermal site.

METHODS AND RESULTS

Three types of geothermal samples were collected: mud, re-injection water, and samples from uncontrolled hydrothermal vents. Isolates grown at 55 degrees C in culture media prepared in sterilized re-injection water, were screened for extracellular enzyme activity by using eight different substrates: casein, carboxymethylcellulose, pectin, polygalacturonic acid (PGA), soluble starch, Tween 20 and 80, and xylan. In total, 109 thermoaerophilic isolates were selected. All of the isolates could hydrolyse Tween 20 (100%) but not Tween 80. Soluble starch was hydrolysed by 96%, casein by 55%, xylan and carboxymethylcellulose by 9%, and pectin and PGA by 2% of the isolates. The isolates were grouped into 14 different homology groups by the restriction pattern analysis of 16S-internal transcribed spacer (ITS) rDNA RFLP. Each of the RFLP groups was also studied by 16S rRNA gene partial sequence analysis. Plasmid DNA profiles revealed that 15 of the isolated strains contained small plasmid DNA molecules ranging in size from 12 000 to 35 000 bp.

CONCLUSIONS

Combined analysis of 16S-ITS rDNA RFLP and 16S rRNA gene partial sequence results indicated the presence of novel or existing species of Anoxybacillus (nine species) and Geobacillus (three species).

SIGNIFICANCE AND IMPACT OF THE STUDY

In this study 16S-ITS rDNA RFLP was applied for the first time to differentiate thermophilic bacilli. It was also the first study on thermophilic bacilli of Balcova geothermal site.

Differentiation of benign and malignant adnexal masses: value of a morphologic scoring system

OBJECTIVE

The purpose of this study was to assess the value of conventional gray-scale ultrasonography, based on a morphologic scoring system, in the differential diagnosis of malignant and benign adnexal tumors.

MATERIAL AND METHODS

A total of 58 adnexal masses in 51 patients were classified prospectively as suggestive of malignant or benign, on the basis of gray-scale ultrasonographic morphology. The results were correlated with histopathological diagnosis.

RESULTS

Histopathology of 42 masses was found to be benign and 16 masses were found to be malignant. On gray-scale analysis 15 of 16 malignant masses were classified as suggestive of malignant and 37 of 42 benign masses were classified as suggestive of benign. The sensitivity, specificity, positive predictive value and negative predictive value are calculated as 93%, 88%, 75%, and 97%, respectively.

CONCLUSION

Prediction of malignancy using gray scale ultrasonograhy based on a morphological scoring system was reliable (NPV = 97%, PPV = 93%). However further investigations about the assessment of adnexal masses with ultrasonography are needed

Effects of laparoscopic tubal ligation on ovarian blood flow and steroidogenesis

Changes in serum ovarian hormone and gonadotrophine levels and ovarian artery blood flow rate by Doppler ultrasonography following laparoscopic tubal sterilization were evaluated. Forty-seven cases of laparoscopic tubal sterilization by electrocoagulation were included in the study. Forty-two women who used nonhormonal contraceptive methods were randomized as a control group. Serum concentrations of estradiol, FSH, LH, progesterone and bilateral ovarian artery pulsatility indexes were measured at baseline and at three, six and 12 months. In the study group, the mean value of midluteal progesterone was significantly decreased three months postoperatively 3. and bilateral ovarian artery pulsatility indexes were increased three and six months postoperatively, compared to their preoperative values. However, there was no statistical difference between bilateral ovarian PI values calculated preoperatively and at 12 months. Laparoscopic tubal ligation by electrocoagulation may temporarily cause reduced bilateral ovarian artery flow and corpus luteum dysfunction proven by low mid-luteal progesterone levels.

Value of glutathion-S transferase pi as a prognostic factor in epithelial ovarian carcinoma

The association between glutathione S-transferase pi (GSTpi) and other clinicopathological parameters, response to chemotherapy and clinical outcome were investigated in chemotherapy naive epithelial ovarian cancer patients. Paraffin-embedded material from 55 patients were used for immunohistochemical analysis. All patients had received six cycles of cisplatinum-based chemotherapy and 41 of them were revalued by laparotomy. Pre- and post-chemotherapy GSTpi staining were detected in the cancer tissues of 18/55 (32.7%) and 5/14 (35.7%) patients, respectively. GSTpi expression was not associated with other clinicopathologic parameters. Of 17 patients with postoperative measurable residual disease clinical response was observed in 4/7 of GSTpi positive and in 9/10 GSTpi negative patients (p = 0.25). Pathologic complete response (pCR) was achieved in 5/8 of GSTpi positive and 11/22 of GSTpi negative cases (p = 0.69). There was no significant difference in overall survival and progression-free survival (PFS) according to initial GSTpi status. However the PFS of the five patients (median 22 +/- 5.9 months) who had postchemotherapy positive GSTpi was significantly shorter than the nine patients (10.0 +/- 2.19 months) who had negative GSTpi (p = 0.006). This difference was not observed in overall survival. These results suggest that initial immunohistochemical staining of GSTpi does not aid in the prediction of pCR and clinical outcome in patients with epithelial ovarian cancer. Nonetheless investigation of GSTpi expression after chemotherapy needs further evaluation.

Identification of extracellular enzyme producing alkalophilic bacilli from Izmir province by 16S-ITS rDNA RFLP

AIMS

To screen industrially important extracellular enzymes from the newly isolated alkalophilic bacilli and to characterize them by phenotypic and 16S-internal transcribed spacer (ITS) rDNA restriction pattern analysis.

METHODS AND RESULTS

Three different environmental samples, soil, leather and horse faeces, were collected within the province of Izmir. Isolates grown on Horikoshi-I medium for 24 h at 37 degrees C were screened for extracellular enzyme activity by using eight different substrates: birchwood xylan, carboxymethylcellulose, casein, citrus pectin, polygalacturonic acid, soluble starch, and Tween 20 and 80. In total, 115 extracellular enzyme-producing bacilli were obtained. Casein was hydrolysed by 78%, soluble starch by 67%, citrus pectin by 63%, polygalacturonic acid by 62%, Tween 20 by 34%, birchwood xylan by 16%, Tween 80 by 12%, and carboxymethylcellulose by 3% of the isolates. The isolates were differentiated into 19 distinct homology groups by the 16S-ITS rDNA restriction pattern analysis.

CONCLUSIONS

Eight different extracellular enzyme activities were determined in 115 endospore forming bacilli. The largest 16S-ITS rDNA homology group (HT1) included 36% of the isolates, 98% of which degraded casein, polygalacturonic acid, pectin and starch.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study is the first report on the characterization of the industrial enzyme-producing alkalophilic bacilli by 16S-ITS rDNA restriction fragment length polymorphism (RFLP). Restriction profiles of 64% of the isolates were found to be different from those of five reference strains used.

Comparison of Subdermal and Peritumoral Injection Techniques of Lymphoscintigraphy to Determine the Sentinel Lymph Node in Breast Cancer

PURPOSE

The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer.

METHODS

Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically.

RESULTS

In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections.

CONCLUSION

The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

The role of chemotherapy in malignant mixed mullerian tumors of the female genital tract

Thirteen patients with malignant mixed mullerian tumor of the female genital tract, treated and followed in our clinic from 1989 to 1999 were retrospectively evaluated. Seven patients (53.8%) with advanced disease or postoperative residual tumor were treated with adjuvant chemotherapy. The median age at diagnosis was 64 years (range: 26-79). All patients underwent primary surgical cytoreduction. Tumors were localized to the endometrium in five (62.5%), to the ovaries in two (25%) and to the fallopian tube in one (12.5%) patient. One patient with endometrial carcinosarcoma had a simultaneous second primary ovarian epithelial carcinoma. Two patients (25%) had a heterologous sarcomatous component. Myometrial involvement included less than half the thickness in one patient, while there was no myometrial invasion encountered in two patients. Five patients (38.5%) had more than 50% of the myometrium invaded. Two patients received additional radiotherapy. Six patients received cisplatinum-based chemotherapy (4 had doxorubicin including combinations), while one patient was treated with a doxorubicin+ifosphamide combination. Five patients (71.4%) had a complete response (CR) to chemotherapy. Response duration in patients with a CR was +13, +67, +10, +14 and +2 months, respectively. After a median follow-up period of 20 months (3-115 months), six patients have died, five are being followed-up with no evidence of disease, one is alive with metastatic disease and one patient is under treatment. Malignant mixed mullerian tumor of the female genital tract is highly responsive to multimodality treatment strategies. Further prospective studies are required to identify distinct prognostic groups that may benefit from various treatment modalities.

The values of intratumoral mast cell count and Ki-67 immunoreactivity index in differential diagnosis of uterine smooth muscle neoplasms

In this study, the role of the count of intratumoral mast cells was examined and compared with the proliferative activity exhibited by Ki-67 indices in the differential diagnosis of uterine smooth muscle tumors. Sixteen cases of leiomyosarcoma, nine cases of atypical leiomyoma and 16 cases of ordinary leiomyoma were included. The pathological features of the cases were determined by reviewing the archive materials including the patient records and hematoxylin-eosin-stained sections. Toluidine blue stain was used to highlight the intratumoral mast cells and they were counted in at least 40 high power fields. A standard streptavidin-biotin method was applied to the sections to highlight the Ki-67 immunoreactive tumor cell nuclei. These proliferative cells were counted in at least 10 high-power fields. Atypical leiomyomas tended to have a higher quantity of intratumoral mast cells than leiomyosarcomas and ordinary leiomyomas (P = 0.027 and P = 0.021, respectively). Leiomyosarcomas tended to have higher Ki-67 immunoreactivity rates than atypical leiomyomas, although the difference was not statistically significant (P = 0.82). We concluded that the quantity of intratumoral mast cells is useful in the differential diagnosis between leiomyosarcomas and atypical leiomyomas, while the cell proliferation rate expressed by Ki-67 immunoreactivity has a limited value.

Hamartomatous endocervical polyp with heterologous mesenchymal tissue

We present an endocervical polyp with heterologous elements. Although a few neoplastic cervical lesions with cartilaginous and adipocytic heterologous tissue have been reported, an endocervical polyp with heterologous cartilage and adipose tissue has not been reported before our case. The patient was a 33-year-old woman who presented with abnormal uterine bleeding. On physical examination, there were no remarkable findings other than a cervical polyp protruding into the cervical canal. The polyp was removed. Pathological examination revealed an endocervical polyp with typical epithelial features. The stroma of the polyp contained mature cartilage islands and adipose tissue. There were also many thick-walled vascular structures. Neither stromal periglandular condensation nor atypia was found. Mitotic figures were not observed. Arteriolar structures did not contain internal elastic lamina. In our opinion, these pathological findings are all consistent with a hamartomatous lesion rather than with a true neoplasm.

Adenomyolipoma of the uterus: a case report

Adenomyolipoma of the uterus is a rare, benign, polypoid lesion considered to be of hamartomatous origin or represent an unusual type of benign Müllerian mixed tumour with a heterologous element. The authors present a case of uterine adenomyolipoma and discuss its pathogenesis. A 62-year-old woman complained of lower abdominal pain and postmenopausal bleeding. Imaging techniques revealed a solid ovarian mass and a polypoid intrauterine lesion. The frozen section diagnosis of the ovarian mass was a thecoma. A total hysterectomy and bilateral salpingo-oophorectomy were performed. On gross examination a pedunculated, polypoid lesion of 7x4.5x3cm was found in the uterine cavity. Microscopically, the polypoid lesion contained both epithelial and mesenchymal elements. The epithelial elements were endometrial glands of various size, formed by proliferative endometrial cells. The mesenchymal elements were composed of endometrial stroma, smooth muscle and mature adipocytes. Both the epithelial and the mesenchymal elements showed a benign appearance, were intermingled with each other and periglandular stromal condensation was absent. The lesion had an irregular surface. Microscopic diagnosis was an adenomyolipoma. The peculiar shape and microscopic features of this lesion suggested that it was a variant of benign Müllerian mixed tumour.

Angiogenesis and p53 protein expression in breast cancer: prognostic roles and interrelationships

The authors have analyzed, on the one hand, the prognostic impact of microvessel density (MVD) and p53 protein expression in patients with breast cancer, and on the other hand, the correlation between the microvascular pattern and the p53 protein expression. Tumors from 120 patients whose paraffin-embedded tissue blocks were available were analyzed using the immunohistochemical method. MVD and p53 protein expression were correlated with histologic grade and tumor size, respectively. The patients with highly vascularized tumor (high MVD) had decreased overall survival (p = 0.04), whereas overexpressed p53 patients did not. In multivariate analysis, axillary lymph node status (p = 0.007), tumor size (p = 0.01), and MVD (p = 0.02) showed important prognostic influence on overall survival. When the simultaneous influence of MVD and p53 protein expression on survival were analyzed, no interrelationship was detected. The results demonstrate the prognostic impact of MVD on overall survival in breast cancer and no association between MVD and p53 protein expression.