Giant solid abdominal mass with cystic lesions: a case report and diaphorodiagnostic approach

A peri-menopausal woman presented with abdominal distention, pelvic discomfort and problems of constipation for the last 4 months. All clinical and radiological examinations were in favor of a giant solid mass with cystic lesions arised from the left ovary. These findings raised suspicion of a primary malignant ovarian tumor or a preudomyxoma peritonei. Surgery revealed a giant mass arised from the uterine fundus. An abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy were preformed. The histological examination verified a degenerated myoma with cystic lesions with no evidence of malignancy. The patient made an uneventful recovery. A gynecologist should always be prepared to perform a different surgery than planned according to operational findings (Fig. 2, Ref. 11).

Diagnostic accuracy of prehysterectomy curettage in determining tumor type and grade in patients with endometrial cancer

OBJECTIVES

We sought to determine the reliability of tumor typing and grading at the prehysterectomy curettage biopsy in patients with endometrial carcinoma. We also wanted to evaluate the overall rate of false-negative diagnosis in the detection of the disease.

METHODS

The final pathologic reports of 263 patients whose diagnosis was endometrial carcinoma were compared with their prehysterectomy curettage reports. We searched for discrepancies between the 2 diagnoses. We also evaluated whether discrepancies varied with respect to the histologic type and tumor grade (endometrioid vs aggressive variant tumours).

RESULTS

Although the statistical analysis predicted accuracy rates of DC diagnosis that exceeded 90%, the true figures proved to be more limited. DC pathology accurately predicted the final histologic result in 67.3% (177/263) of patients and the final tumor grade in 55.5% (146/263). Regarding the latter, we found 37.3% (98/263) of patients with undergraded tumors and 7.2% (19/263) with overgraded ones. The histologic type of the carcinoma crucially affected the diagnostic reliability of DC. Nevertheless, the overall false-negative rate in establishing the diagnosis of carcinoma was 7.6% (20/263).

CONCLUSIONS

DC is a reliable procedure for establishing the diagnosis of endometrial cancer. Its capability to correctly characterize the final histologic type varies significantly but is satisfactory overall and captures approximately three quarters of the patients; however, the procedure significantly underestimates tumor grade. The limitations of DC are due to the blindness of the sampling procedure.

Preoperative work-up of early cervical cancer (stages Ib-IIa)

OBJECTIVE

To determine the effectiveness of preoperative investigations in early cervical cancer.

MATERIALS

We retrospectively reviewed the medical records of 309 patients with previously untreated early cervical carcinoma who completed pretreatment evaluation at "St. Savas" Cancer Hospital of Athens and "Metaxas" Memorial Hospital of Peireas between January 1986 and September 1, 2000. Ages ranged from 18-77 years old with a mean age of 48 and S.D. of 12.25. FIGO staging was Ib (200 pts.), IIa (105 pts.), IV (4 pts.). Histologic type was squamous (267 pts.), adenoid (35 pts.), adenosquamous (7 pts.). The patients were clinically examined and routinely evaluated with blood work-up, chest X-ray, IVP, abdominal CT scan, barium enema, sigmoidoscopy, cystoscopy, and/or urine cytology. Patients with early stage cervical carcinoma were treated with Wertheim-Meigs radical hysterectomy and pelvic lymphadenectomy, while those with advanced stage cervical carcinoma were treated with radiotherapy and chemotherapy.

RESULTS

In urinary tract investigation, CT showed a sensitivity of 100% and a specificity of 99.67%. In gastrointestinal tract investigation CT showed a sensitivity of 50% and a specificity of 99.67%. When we compared the histologic findings of the pelvic lymph nodes that were extracted in surgically treated patients with the preoperative CT findings, we found that CT had a sensitivity of 63.33% and a specificity of 88.57%.

CONCLUSION

In our series of patients with early stage cervical carcinoma, imaging and endoscopic tests added limited information over pelvic examination and altered in four cases (1.29%) the choice of the appropriate treatment modality. CT scans proved adequate in this series of patients in the evaluation of the bladder and colon. All other tests could have been performed only when CT was suspicious of invasion. Moreover, CT served as a baseline examination for future comparative studies in the follow-up of patients.

Preoperative imaging of primary intra-abdominal gynaecological malignancies. Diagnostic accuracy of CT-scan and MRI. A Greek cohort study

OBJECTIVES

To determine the radiological modalities that provide at the initial workout the most accurate information regarding the operability and the type of operation for patients with primary cervical, endometrial, and ovarian carcinomas.

PATIENTS AND METHODS

The medical records of 611 patients with gynaecological cancer were reviewed. The preoperative radiological findings were compared with the intraoperative and pathological ones. The diagnostic accuracy of CT and MRI at various sites was evaluated for all three kinds of carcinoma in combination.

RESULTS

MRI was more accurate than CT in determining cervical enlargement (82% vs 73%), parametrial invasion (91% vs 74%) and the only examination that could evaluate cervical tumour size as well as cervical stromal and myometrial infiltration. Regarding lymph node involvement their results were similar (86% vs 88%). Both methods were comparably accurate in evaluating ovarian tumours (82% vs 84%), ascites (82% vs 81%), omental (73% vs 77%) and mesenterial infiltration (88% vs 93%). They also proved to be highly accurate (100% vs 98%) in the evaluation of solid abdominal organs.

CONCLUSIONS

Non-enchanced MRI should only be used for the preoperative evaluation of a patient with cervical carcinoma, while CT with intravenous and per os contrast media for one with ovarian cancer. Regarding patients with endometrial cancer, no high-resolution method is required for endometrioid grade I tumours, while contrast-enchanced MRI should be employed for all other cases.

Intraoperative gross examination of myometrial invasion and cervical infiltration in patients with endometrial cancer: decision-making accuracy

OBJECTIVES

We sought to determine the accuracy of gross evaluation of the depth of myometrial invasion and the involvement of the cervix, and its value in determining the need for extensive surgery in patients with endometrial carcinoma.

METHODS

The intraoperative records of 256 patients operated for endometrial cancer were used to compare the gross evaluations with the final microscopic histopathological findings. In the theater, the uterus was opened and inspected after its removal. The depth of myometrial invasion was noted as less or greater than 50% using a full-thickness incision through the tumor, while cervical involvement was noted as positive or negative, based on extension of the tumor below the internal cervical os. Standard statistical calculations were used to determine accuracy, sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates of the method.

RESULTS

Regarding the depth of myometrial invasion, gross evaluation could accurately predict the final result in 88.2% of patients. Sensitivity, specificity, positive, and negative predictive values were 83.7, 90.6, 82.8, and 91.1%, respectively. False-positive results were noted in 9.4% of cases and false-negative in 16.3%. Analysis of the characteristics of the false-negative patients showed that they had aggressive variant tumors, tumors of advanced grade, and tumors that more frequently had developed from an atrophic endometrium. With respect to cervical involvement, gross evaluation had an overall accuracy of 98.5%, 0% false-positive rate, 11.5% false-negative rate, 88.5% sensitivity, 100% specificity, 100% positive predictive value, and 98.3% negative predictive value.

CONCLUSION

Our data suggest that visual gross examination of the uterus provides safe and reliable estimates of both myometrial invasion and cervical infiltration. So, the surgeon can rely on the procedure to decide the need for further operative manipulations.

Prognostic significance of factors affecting disease free interval and overall survival for Stage II breast cancer in Greece. A multivariate cohort study

BACKGROUND

Univariate analysis evaluates the impact of a prognostic factor on survival rates, either disease free (DFI) or overall (OS). Since many of the factors are interrelated, it is difficult to predict the prognosis of an individual patient. Multivariate analysis is therefore required in order to allow factors act together thus ending in the best possible combined predicting result.

METHODS

A step-up procedure (Cox's Proportional Hazards Regression model) was used to include various prognostic parameters, relating to patients themselves, to the pathology of their tumours and to the treatment schedule followed. Two hundred and sixty-nine Stage II breast cancer Greek patients, treated from 1981 until 1991 and with a median 12-year of follow-up are studied.

RESULTS

Five factors were found to be significant for patients DFI. In order of relevant importance, these were the number of infiltrated nodes, tumour size, postoperative radiotherapy, adjuvant chemotherapy and patients age. Regarding patients OS, tumour size, number of positive nodes, patients' age at entry and ER/PR status were the most important ones.

CONCLUSION

Our long-term (12-year), single institution, single area results, suggest that, the prognostic factors for patients DFI and OS are the same with those of series from Europe and USA. Additionally, they remain unchanged after long-term follow-up, compared to a previously reported short-term national-wide study from this country.

Adjuvant tamoxifen versus tamoxifen plus CMF in the treatment of early breast cancer in Greece. Fifteen-year results of a randomised prospective trial and the potential risks of the antioestrogen

BACKGROUND

CMF and Tamoxifen are the most commonly administered drugs for the adjuvant treatment of early-stage breast cancer. We present the 15-year follow-up of our 250-patient series and evaluate the oestrogenic side-effect of Tamoxifen on the endometrium.

PATIENTS AND METHODS

250 women entered this prospective study from 1981-1986. They had all undergone modified radical mastectomyl and were randomly assigned to receive either Tamoxifen only for 4 years or combination of Tamoxifen with 6 cycles of standard CMF. Abdominal sonogram was used to determine endometrial thickness, with 6 mm as cut-off limit for endometrial biopsy.

RESULTS

After 15.6 years of follow-up DFS and OS rates were better for the CMF + Tamoxifen, group (52.8% vs 39.2%--p = 0.043 and 57.6% vs 40.8%--p = 0.006 respectively). Only patients with more than 4 infiltrated nodes did not significantly benefit from adjuvant CMF. Postmenopausal women suffered more proliferative endometria compared to premenopausal ones (40.3% vs 15.6%), while life-threatening lesions (cancer and atypias) were found in 3.3% of the postmenopausal patients only.

CONCLUSION

CMF + Tamoxifen combination offers better long-term results for early-stage breast cancer patients. Dose reduction must be avoided if maximum results are to be achieved. More than 4 positive nodes seem to require additional chemotherapeutic manipulation. Tamoxifen's oestrogenic side-effect on the endometrium is quite common, but life-threatening lesions are rare, thus proving the drug's safety.

Unusually prolonged ovarian function ending in endometrial cancer development. A case report

An unusual case of overprolonged ovarian function in a 77-year-old woman that ended in the development of endometrial cancer is presented in this paper. The established knowledge of the correlation of uncontrolled oestrogen activity to this type of cancer is evaluated and correlated with our patient's hormonal readings.

The prognostic significance of second-look laparotomy in advanced ovarian cancer

The value of prognostic parameters in predicting the outcome of second look laparotomy (SLL) and survival after SLL was assessed in a series of 115 FIGO III and IV ovarian cancer patients. The prognostic parameters included age of patients, FIGO-stage, differentiation of tumour, maximum diameter of residual disease following the initial operation and clinical, cytologic and histologic results of SLL. No statistically significant difference was found between stage III and IV patients concerning the results of SLL (p = 0.99) and the same is true for the tumour differentiation (p = 0.1) and the age of the patient when first operated (p = 0.15). On the contrary, residual disease following the initial operation is shown to be prognostically significant (p = 0.001). As for the overall survival time, the amount of residual tumour after the SLL is shown to be the most important parameter (p = 0.0002).