Primary peritoneal carcinoma: a report of twelve cases and a review of the literature

Primary peritoneal carcinoma (PPC) is rare tumor histologically identical to epithelial ovarian carcinoma (EOC); it is differentiated from EOC based on the extent of gross ovarian involvement and microscopic invasion of the cortex. We report 12 cases of PPC which were diagnosed in our Department during a 9-year period. Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy were performed in 9 patients, while 3 underwent only explorative laparotomy with bilateral salpingo-oophorectomy. All patients were treated with postoperative platinum-based chemotherapy. After a median follow-up of 42 months, only 5 patients are alive without disease. PPC is a rare tumor currently managed in the same way as ovarian cancer. Primary debulking surgery and chemotherapy represent the cornerstones of treatment. Considering the limited number of patients with PPC, no definitive conclusion can be drawn concerning the prognostic factors for survival.

Aggressive angiomyxoma of the pelvis. A case report

Aggressive angiomyxoma is a locally mesenchymal, benign, and rare neoplasm. The vulva, perineum, and pelvis are the most common sites of involvement. The preoperative diagnosis is postulated by CT, sonography, MR image and angiography. The immunohistochemical study reveals the definitive diagnosis. The therapy is only surgical, and because of its tendency to recur locally, the excision has to be as complete as possible.

Reversal of foetal hydrops and foetal tachyarrhythmia associated with maternal diabetic coma

Foetal hydrops is always a challenge for the clinician. We report a case of tachycardia associated with hydrops and hydramnios in a pregnancy complicated with diabetic coma at 28 weeks gestation. Normal foetal heart rate was recorded immediately after correction of maternal acidotic status and hydrops eventually disappeared. The woman was delivered at 32 weeks and the baby had an uncomplicated postnatal course. We hypothesise that maternal ketoacidosis has been the precipitating factor of tachycardia and congestive heart failure and that this case is conceptually similar to the "late death" phenomenon, reported in cases of poorly controlled maternal diabetes.

Large-cell variant of small cell carcinoma of the ovary with hypercalcaemia

A rare case of large-cell variant of hypercalcemic small cell carcinoma of the ovary diagnosed in a 17 year-old girl is presented and discussed. The patient died of disease progression and severe hypercalcemia within 25 months of diagnosis.

Legionnaire's disease complicating pregnancy: a case report with intrauterine fetal demise

OBJECTIVE

Legionnaire's disease complicating pregnancy is an unusual event that can seriously compromise both the mother and the fetus.

CASE REPORT

We describe one case of such association, with an unfavourable intrauterine fetal outcome, secondary to acute placental insufficiency, related to infection.

DISCUSSION

It is important in these high risk pregnancies complicated by acute pneumonia to take into consideration the diagnosis, as early as possible, and the appropriate treatment or the careful monitoring of fetal wellbeing.

Transforming growth factor-beta1 in hemangioma of the ovary

Hemangioma of the ovary is extremely rare. We report the case of a 32-year-old woman who complained of pelvic pain due to a large right adnexal mass. On surgical exploration a 10 x 8 cm hemangioma of the ovary was resected. Expression of transforming growth factor-beta1 was studied, and the possible role of this molecule in the development of the tumor is discussed.

Endoscopic examination of the fetus in early pregnancy

OBJECTIVE

To assess if fetal examination is feasible by endoscopy in the late first-early second trimester.

SETTING

Tertiary referral center for high risk obstetrics and genetics.

PATIENTS AND METHODS

Patients (total number 9) submitted to pregnancy termination for social reason (7) or for chromosomal abnormality (2) between 10 and 14 weeks of pregnancy. Visualisation of the foetus by a transabdominally introduced endoscope (19 gauge) under local anaesthesia. Step by step examination of the foetal contour and double check of the recordings by a senior Pathologist.

RESULTS

Patients complained no serious discomfort. Visualisation was accomplished in all cases with ease and the images were judged satisfactory by the Pathologist. Fetal examination was found easier at 10-12 weeks of gestation rather than at 13-14 weeks.

DISCUSSION

Endoscopy is a simple and well tolerated procedure, which enables precise visualization of external fetal anatomy as early as the first trimester of gestation. Therefore it can be proposed before surgical termination of pregnancy.

[Reconstructive surgery in oncological gynecology. Our experience]

BACKGROUND

Personal experience in reconstructive surgery for gynecologic oncology is reported. These techniques are playing, during last years, a leading role since it is necessary to assure a good treatment and top quality lifestyle to oncologic patients.

METHODS

A retrospective study was made on 357 major surgical treatments for neoplastic disease at the IInd Clinic of Obstetrics and Gynecology, University of Bari. For each disease the technique, the length of surgery and possible complications have been reported. In total 50 reconstructive procedures on 357 surgical interventions for gynecologic neoplastic disease (14%) were made.

RESULTS

There was no rate of mortality, and the complications were found only in 5 patients (10%).

CONCLUSIONS

Reconstructive surgery can increase surgical radicality, improve the quality of life of the patients and reduce the postoperative complications.

Immunological markers in HIV-infected pregnant and non-pregnant women

OBJECTIVE

To assess the influence of pregnancy on the course of HIV infection by comparing the behaviour of total lymphocyte counts and lymphocyte subsets (CD4(+) and CD8(+) and their ratio) in a cohort of infected pregnant women.

SETTING

Tertiary referral centre for high risk obstetrics and infectious diseases in pregnancy.

PATIENTS AND METHODS

A prospective study was designed, HIV infected women being enrolled at the beginning of pregnancy and sampled each trimester and in the puerperium. As controls, a group of non-pregnant HIV-infected women, cross-matched for age, risk factors and stage of disease were included and similarly evaluated in the same period.

RESULTS

All the parameters, when longitudinally evaluated, were stable during gestation. Compared with non-pregnant subjects, patients had higher CD4(+) counts at the beginning and increased values of total lymphocytes count and subsets during the puerperium. Antepartum and postpartum risk factors such as drug abuse, smoking, antiretroviral therapy, length of gestation, maternal complications and HIV status of the neonate were not influential on the total lymphocytes counts and subsets.

DISCUSSION

According to this data, pregnancy per se seems to have a negligible influence over the course of HIV infection, at least as far as immune parameters are concerned.

Maternal complications after caesarean section in HIV infected women

OBJECTIVE

To assess the intervention related risk in HIV-infected women, undergoing caesarean section (CS).

SETTING

Tertiary care center for high risk obstetrics and infectious diseases in pregnancy.

PATIENTS AND METHODS

Thirty-three HIV-positive women and one hundred and sixty-eight controls, cross matched for age, weight, parity, obstetrical characteristics at delivery and indication for CS, were prospectively recruited for the study. Infection related characteristics, as mode of acquisition, drug abuse, immune status and stage of disease were also recorded. Complications of the intervention were evaluated according to infectious status and risk factors.

RESULTS

Post-operative complications were significantly more frequent among HIV-infected mothers. More advanced disease and maternal age were the risk factors statistically related to complications.

DISCUSSION

According to our data, CS carries a higher chance of post-operative complications in HIV-infected women, these complications being also related with the severity of infection (stage and duration of the disease). Given the characteristics of the population in the study (mode of acquisition, prevalence of early stage of the disease), the rate of complication is still relatively low compared to non-western, malnourished, drug-abusers groups.

[Combination of cisplatin and vinorelbin in the neoadjuvant treatment of locally advanced cervical carcinoma. Phase II study]

BACKGROUND

Aim of this phase II study is to evaluate the cytoreductive efficacy and the toxicity of a regimen consisting of cisplatin and vinorelbine as neoadjuvant chemotherapy for three cycles every 21 days in patients with locally-advanced cervical carcinoma.

METHODS

Between April 1996 and December 1998, 33 untreated patients with locally-advanced cervical carcinoma received neoadjuvant chemotherapy with cisplantino 80 mg/m2 (day 1) plus vinorelbine 25 mg/m2 (day 1 and 8). Within 28 days from completion of chemotherapy patients in complete or partial response were submitted to radical hysterectomy plus pelvic lymphadenectomy.

RESULTS

Twenty-six patients (79%) were submitted to radical surgery; four patients were not submitted to surgery because of poor response to treatment, two for anesthesiological contraindications and one refused surgery. The combination of cisplatin plus vinorelbine in this phase II study induced a clinical overall response rate of 90%, with 8 pathologic complete response (24%).

CONCLUSIONS

The association of cisplatin and vinorelbine as neoadjuvant chemotherapy in locally-advanced cervical carcinoma showed to be safe and effective with a low cost and poor toxicity.

Splenic involvement in ovarian cancer. Description of three cases

Metastatic involvement of the spleen in patients with ovarian cancer is unusual. Solitary splenic metastasis in the absence of disseminated disease are rare. Three cases of advanced ovarian cancer with splenic involvement are reported. The splenectomy was adopted in two patients.

Surgical decompression and radiation therapy in epidural metastasis from cervical cancer

Spinal cord compression by epidural metastasis is considered an exceptional complication in patients with cervical carcinoma. We report three patients treated for a cervical carcinoma who developed epidural metastasis with spinal cord compression at 9, 25 and 48 months after primary treatment of the uterine malignancy. All patients had poorly-differentiated adenocarcinomas with lymphovascular space invasion, and two had lymph node metastasis. All patients underwent emergency decompressive laminectomy followed by radiotherapy and a partial recovery of the neurological function was achieved. In two patients the spinal cord was the only site of recurrent disease, whereas the other had lung and brain metastasis at the time of epidural involvement diagnosis. All three patients, however, died of disseminated disease. Surgical decompression followed by radiation therapy may result in a complete preservation of the neurologic functions in patients with spinal cord compression secondary to metastatic carcinoma of the uterine cervix. Considering the propensity for disseminated disease, long term survival might be achieved only with the use of effective chemotherapy.

Predictive value of serum androstenedione basal levels on the choice of gonadotropin or laparoscopic ovarian electrocautery as ovulation induction in clomiphene citrate-resistant patients with polycystic ovary syndrome

Therapeutic approaches to chronic anovulation from polycystic ovaries in clomiphene-resistant infertile patients are under debate. This study discusses evidence that supports the possible predictive value of serum basal level of androstenedione in the choice of the better therapy between laparoscopic ovarian electrocautery and ovulation induction. Lower androstenedione levels seem to be correlated with a better ovarian response after ovulation induction with gonadotropins, while high androstenedione levels are associated with a higher incidence of conception after laparoscopic ovarian electrocautery. Obesity does not seem to represent a hindrance to laparoscopic treatment.

[Echographic measurement of subcutaneous adipose tissue as fetal growth index]

OBJECTIVE

To evaluate, by 3rd trimester ultrasound examination, fetal adipose tissue to predict fetal growth and birthweight.

PATIENTS AND METHODS

Thirteen pregnant women (group 1) with uncomplicated pregnancy and 9 diabetic women (group 2) have been enrolled. We have examined adipose tissue at the cross sectional level of arm, thigh and abdomen and at the longitudinal sectional level of shoulder. During 3rd trimester measurements were taken at the beginning (28-32 gestational weeks), at the middle (34-38 gestational weeks) and at term (39-41 gestational weeks). At birth we recorded the skinfolds of arm, thigh and shoulder and the neonatal weight. Subsequently, by regression analyses ultrasound parameters of physiological pregnancies were correlated to skinfolds measurements at birth, while abdomen thickness was compared to birthweight. In addition, ultrasound markers of the physiological pregnancies were compared to those of diabetic pregnancies by the t-test.

RESULTS

Fetal limbs examination had not a prognostic value at any gestational week. Shoulder ultrasound measurements appeared well correlated to the shoulder skinfold after birth since the 34th week. Diabetic mothers' fetuses presented much more adipose tissue than control cases, particularly of arm and thigh at 28-32 weeks, of shoulder at 34-38 weeks and in all the markers at term pregnancy.

CONCLUSION

Ultrasound examination of fetal adipose tissue seems to have a predictive value for fetal growth both in physiological and diabetic pregnancy.

The diagnostic role of "in utero" magnetic resonance imaging

OBJECTIVE

To assess the diagnostic potential of Magnetic Resonance Imaging (MRI) in the management of ultrasonically diagnosed congenital anomalies.

PATIENTS AND METHODS

Ninety-two patients were included into the study after the ultrasonic diagnosis of an abnormality. Sixty-three of these patients were affected by an abnormality of the central nervous system (CNS) and 29 by abnormalities in other apparatuses. The GRE technique was used to obtain T1 and T2 star-weighted images.

RESULTS AND DISCUSSION

Satisfactory imaging was obtained in all but one case. In order to define the "reliability" of MRI for a given condition, a diagnostic score was designed and separately given by the obstetrician and the radiologist involved in the case. MRI scored less than ultrasonography for abnormalities of the fetal contour and for large and complex distortion of the CNS as holoprosencephaly. For subtle midbrain anomalies, as well as for neuronal migration disorders, MRI definitely was superior to sonography. For other anomalies, as for example congenital diaphragmatic hernia, MRI was better than conventional techniques in assessing prognosis and outcome, but less reliable in assessing associated anomalies. MRI seems to be a valuable adjunct to us for prenatal diagnosis of only selected fetal anomalies and requires precise guidelines in a multidisciplinary approach to prenatal pathology.

[Chemotherapy in the treatment of ovarian carcinosarcoma]

Carcinosarcoma of the ovary is a rare neoplasm representing 1% of this organ malignancies. The disease appears almost exclusively in advanced stage having an unfavourable prognosis. Three patients affected by carcinosarcoma (MMMT) of the ovary admitted to our Operative Unit have been treated. All patients underwent surgery and subsequently chemotherapy. Two patients were affected by heterologous MMMT and were stage IV and IIIc respectively, the other one, affected by homologous MMMT, was stage IIIc. Stage IV patient was submitted to 6 cycles of CARBO + IFX + CDDP, second look and further 6 cycles of TAX. After 23 months she was submitted to colostomy for intestine occlusion. At the 35 months she died for cachexia and intestine occlusion. Stage IIIc heterologous patient was submitted to 6 cycles of CDDP + EPI + IFX + MESNA for 3 days; at 6 months from diagnosis she did not present any sign of disease. Stage IIIc homologous patient, affected by chronic renal insufficiency and submitted to dialysis, underwent 5 cycles of TAX and at 11 months from diagnosis presented partial response. Carcinosarcoma of the ovary, because of its rarity, and of the poor record of cases in the literature, is a much debated topic in particularitis complementary therapy. Opinions of the several authors are in contrast regarding the use of CHT + RT at the same time. Only RT after surgery does not seem to improve the survival of these patients. Personal experience, with the reported outlines, compared with survival, seems to confirm the use of CDDP and of IFX and to give new horizons to TAX, waiting for further findings.

[The correlation between idiopathic leukocytospermia, embryo quality and outcome in the FIVET and ICSI procedures]

BACKGROUND

An adverse effect of leukocytospermia in seminal fluid on motility and fertilizing power of spermatozoa has been described. This detrimental effect could be mediated by radical oxygen species (ROS). Recently, a direct effect on nuclear DNA of sperm induced by ROS has been described, although the chance of fertilization did not seem altered during ICSI procedure. Aim of this prospective case-control study was to compare the outcome of results in term of fertilization rate and embryo quality in patients with and without idiopathic leukocytospermia during IVF and ICSI cycles.

METHODS

Seventy-two patients selected for a program of IVF and ICSI were admitted in the study. Fourty-two patients underwent IVF procedure, 14 with idiopathic leukocytospermia and 28 without, and thirty underwent ICSI procedure, 16 with leukocytospermia and 14 without leukocytospermia.

RESULTS

Statistical significant differences on cleavage rate of embryos between leukocytospermia and control group in IVF cycles were observed. In ICSI procedure a low fertilization, cleavage rate and percentage of good embyros in the presence of leukocytospermia were evidenced.

CONCLUSIONS

The presence of a significant number of leukocytes in semen, even in idiopathic condition, could affect the results of IVF and ICSI procedure. An adverse effect of lipoperoxidation process of plasma membrane and damage of nuclear chromatin of sperm, as result of leukocyte contamination could be hypothesized and future studies needed in order to verify the role of ROS on sperm functions.

Transvaginal sonography and hysteroscopy in postmenopausal uterine bleeding

OBJECTIVE

To compare the diagnostic accuracy of transvaginal ultrasound and hysteroscopy in the detection of endometrial pathologies in women with postmenopausal bleeding not using hormonal replacement therapy (HRT).

METHODS

Between January 1997 and April 1998, 106 postmenopausal women with uterine bleeding not using HRT underwent a diagnostic work-up including pelvic examination, transvaginal ultrasound, hysteroscopy and endometrial biopsy. Sonographic measurement of endometrial thickness and hysteroscopic findings were compared with histological results. The 'classification tree' method was used to identify cut-off values of sonographic endometrial thickness that could be indicative of a class of uterine pathology. Statistical analysis was performed with the McNemar test.

RESULTS

No case of endometrial cancer was found with a cut-off point of 5 mm of endometrial thickness evaluated by ultrasound, whereas all patients with endometrial thickness > or = 15 mm at sonography had an endometrial carcinoma. In the group of patients with endometrial thickness between 6 and 14 mm, we found normal atrophic endometria, benign and malignant pathology. On the other hand, the McNemar test showed a very good correspondence between hysteroscopy and histology (sensitivity 97.5% and specificity 100%), confirming its usefulness in diagnosis of postmenopausal uterine bleeding.

CONCLUSIONS

Transvaginal ultrasound has revealed some limitations, mainly in the group of patients with endometrial thickness between 6 and 14 mm. The absence of endometrial malignancy in women with endometrial thickness < or = 5 mm and the high possibility of cancer in those with endometrial thickness > or = 15 mm should be confirmed in larger series. Hysteroscopy proved to be a simple and safe outpatient procedure with a high diagnostic accuracy, and in our opinion it should be considered in all women with postmenopausal uterine bleeding.

Hypersensitivity reactions in ovarian cancer patients receiving paclitaxel

OBJECTIVE

The aim of this study was to describe a rapid retreatment strategy in patients with paclitaxel hypersensitivity reactions.

METHODS

A retrospective review of all patients receiving standard 3-hour infusion paclitaxel-based chemotherapy after proper premedication at the Department of Gynecologic Oncology, University of Bari between 1995 and 1998, was performed. All patients who developed hypersensitivity reactions to paclitaxel were identified and their treatment course and outcome were reviewed. A review of the literature on this subject is also presented.

RESULTS

Eighty-six women were treated with 461 cycles of paclitaxel-based chemotherapy at our Unit. Twelve patients (14%) developed hypersensitivity reactions. All had received standard premedication consisting of corticosteroids and hystamine blockers. Hypersensitivity reactions consisted of isolated face flushes (3 patients), dyspnea and chest tightness (4 patients) or bronchospasm (5 patients). Eleven patients were rechallenged with the original paclitaxel solution starting at a slower rate after a second premedication with a double dosage of steroids. None of these patients had reactions in subsequent courses. Only one patient (the first of this series treated in February 1995), was retreated 5 days later under strict monitoring in intensive care unit.

CONCLUSIONS

Retreatment with the original paclitaxel solution is safe in almost all patients with hypersensitivity reactions. The drug should be administered within the next 24 hours with a new premedication protocol.