Ovarian metastasis of primary biliary and gallbladder carcinomas

The ovary is a frequent site of metastasis from a wide variety of malignant neoplasias, with the majority originating in the GI tract. The best known tumor of this type is signet ring cell adenocarcinoma (Krukenberg tumor). The gallbladder and bile ducts are rare sources of these metastases. We are reporting two such cases in which the patients presented with no hepatic symptoms and vague gastrointestinal complaints. The gallbladder and bile duct carcinomas were incidental findings during exploratory laparatomy for an ovarian mass.

The influence of cytoreductive surgery on survival and morbidity in stage IVB endometrial cancer

The purpose of this study was to detect possible survival advantages of surgical cytoreduction and different adjuvant treatment regimens for stage IVB endometrial cancer patients, and also to evaluate the prognostic importance of surgico-pathological risk factors and surgical morbidity rates. Thirty-seven FIGO stage IVB endometrial cancer patients treated at the Hacettepe University Hospital between 1977 and 1998 were included in this study. Clinical data were obtained from the private oncology files and all specimens were re-evaluated by the co-author pathologist. Optimal cytoreduction was defined as a surgical procedure leaving the patient with < or =1 cm residual disease in maximal diameter. All patients were subjected to initial cytoreductive surgery, but it had been achieved for 22 (60%) patients. Fourteen (38%) patients received both radiotherapy and chemotherapy, 10 (27%) patients received only radiotherapy and the other 10 (27%) patients received only chemotherapy. Three patients refused any type of adjuvant therapy. The median survival of the suboptimally cytoreduced patients was 10 months, while the median survival in the optimal group was 25 months (P = 0.001). In optimal cytoreduction group, the median survival for 12 (55%) patients without visible tumor was 48 months compared to 13 months in 10 (45%) patients with visible tumor. As an adjuvant treatment, concomitant cisplatin and radiotherapy revealed 54 months median survival compared to 15 and 13 months in patients treated with only radiotherapy and only chemotherapy, respectively. By univariate analysis, extra-abdominal metastases, suboptimal cytoreduction, visible tumoral mass after cytoreduction, pelvic-para-aortic lymphatic metastases, and cervical invasion were found to be significant predictors of poor survival. In multivariate analysis, optimal cytoreduction, concomitant cisplatin-radiotherapy treatment, and extra-abdominal metastases were significant. Morbidity was mild in six (16%), and severe in nine (24%) patients. We conclude that optimal cytoreduction achieved significant survival benefit for stage IVB endometrial cancer patients with a reasonable surgical morbidity rate. As an adjuvant treatment, concomitant cisplatin and radiotherapy was the best choice.

Reproductive tract pathology in asymptomatic women treated with tamoxifen

PURPOSE

To determine the long-term effects of tamoxifen on the female reproductive tract in patients with breast cancer.

METHODS

Forty-nine patients with breast cancer receiving tamoxifen longer than two years were analyzed. All the patients underwent pelvic examination, pap smear, transvaginal ultrasonography, serum CA 125 and dilatation and curettage.

RESULTS

There were 16 patients with genital system pathology. Three of them had atypical Pap smears, one with cervical carcinoma and the other two with chronic cervicitis. Two significant ovarian pathologies were found. These were ovarian fibroma, and unilateral dermoid cyst. There were three patients with endometrial hyperplasia without atypia. Uterine myoma was encountered in seven of the cases. Only one patient had elevated CA 125 levels despite normal genital examination findings.

CONCLUSION

Since no significant genital pathology attributable to tamoxifen therapy could be detected, the follow-up for gynecologic pathologies in breast cancer patients receiving tamoxifen therapy may be individualized.

The influence of cytoreductive surgery on survival and morbidity in stage IVB endometrial cancer

The purpose of this study was to detect possible survival advantages of surgical cytoreduction and different adjuvant treatment regimens for stage IVB endometrial cancer patients, and also to evaluate the prognostic importance of surgico-pathological risk factors and surgical morbidity rates.

Thirty-seven FIGO stage IVB endometrial cancer patients treated at the Hacettepe University Hospital between 1977 and 1998 were included in this study. Clinical data were obtained from the private oncology files and all specimens were re-evaluated by the co-author pathologist. Optimal cytoreduction was defined as a surgical procedure leaving the patient with ≤1 cm residual disease in maximal diameter. All patients were subjected to initial cytoreductive surgery, but it had been achieved for 22 (60%) patients. Fourteen (38%) patients received both radiotherapy and chemotherapy, 10 (27%) patients received only radiotherapy and the other 10 (27%) patients received only chemotherapy. Three patients refused any type of adjuvant therapy.

The median survival of the suboptimally cytoreduced patients was 10 months, while the median survival in the optimal group was 25 months (P = 0.001). In optimal cytoreduction group, the median survival for 12 (55%) patients without visible tumor was 48 months compared to 13 months in 10 (45%) patients with visible tumor. As an adjuvant treatment, concomitant cisplatin and radiotherapy revealed 54 months median survival compared to 15 and 13 months in patients treated with only radiotherapy and only chemotherapy, respectively. By univariate analysis, extra-abdominal metastases, suboptimal cytoreduction, visible tumoral mass after cytoreduction, pelvic-para-aortic lymphatic metastases, and cervical invasion were found to be significant predictors of poor survival. In multivariate analysis, optimal cytoreduction, concomitant cisplatin-radiotherapy treatment, and extra-abdominal metastases were significant. Morbidity was mild in six (16%), and severe in nine (24%) patients.

We conclude that optimal cytoreduction achieved significant survival benefit for stage IVB endometrial cancer patients with a reasonable surgical morbidity rate. As an adjuvant treatment, concomitant cisplatin and radiotherapy was the best choice.

Diagnostic and prognostic value of serum and peritoneal fluid lactate dehydrogenase in epithelial ovarian cancer

OBJECTIVE

The aim of this study was to investigate the peritoneal fluid and serum lactate dehydrogenase (LDH) levels in patients with ovarian masses.

MATERIALS & METHODS

Peritoneal fluid and serum lactate dehydrogenase (LDH) levels were measured in 27 patients with epithelial ovarian carcinoma and 38 with benign ovarian tumors. Serum and peritoneal fluid LDH levels were also compared with the levels of CA-125.

RESULTS

Both of the marker levels in ovarian cancer patients were significantly higher than those in patients with benign ovarian tumors. Serous and undifferantiated carcinomas presented higher marker levels than endometrioid and mucinous carcinomas. High grade, advanced stage and positive cytology were associated with higher serum and peritoneal fluid LDH levels; there was an inefficient correlation between them but, when these two markers were used together with CA-125, sensitivity of CA-125 increased to 70%.

CONCLUSIONS

In conclusion, serum LDH can be used to discriminate adnexal mass origin and peritoneal fluid LDH may have prognostic value because of the strict relationship with advanced stage, poor histologic type, higher grade and positive abdominal cytology. Peritoneal LDH is found to be a reliable biochemical marker related to prognosis in ovarian carcinoma patients.

Comparison of enoxaparin and standard heparin in gynaecologic oncologic surgery: a randomised prospective double-blind clinical study

OBJECTIVE

This study aimed to compare the haemorrhagic complications and efficacy of enoxaparin, a low molecular weight heparin (LMWH), and conventional standard heparin (SH) in gynaecological oncologic surgery.

MATERIALS METHODS

A double blind, randomised trial was performed on 102 consecutive women undergoing gynaecologic cancer surgery with pelvic and paraaortic lymphadenectomy. The women were separated into those who were given 2,500 IU enoxaparin once daily and SH in a dose of 5,000 IU three times daily. The groups were analysed for intraoperative blood loss, drainage, transfusion requirements, perioperative haemoglobin decrease, wound haematoma, and clinical deep venous thrombosis.

RESULTS

The two groups were well matched for age, weight, and other factors, which could predispose to the development of deep venous thrombosis (DVT) and haemorrhage. No patient developed clinical significant DVT, wound haematoma or intra-abdominal bleeding. There was no significant difference in bleeding complications between the two regimens. The antiFXa level in the plasma was correlated strongly with patient weight.

CONCLUSIONS

A dose of 2,500 IU enoxaparin/day does not cause more bleeding complications than SH 5,000 IU three times daily when used to prevent thrombosis. However, the dose of enoxaparin must be adjusted to the patient's weight.

Inflammatory breast metastases of ovarian cancer: a case report

BACKGROUND

Metastasis to the breast from extramammary malignancies is rare.

CASE

A 35-year-old woman presented with bilaterally inflammatory breast involvement, 2 years after the diagnosis of stage IIIC epithelial ovarian cancer. Neoplastic tissue was immunohistochemically positive using antibodies against OC125 and negative for gross cystic disease fluid protein-15 (BRST-2) and estrogen receptor in biopsy material in the breast. Combination chemotherapy consisting of paclitaxel, cisplatin, and anthracycline was started. She died 18 months after the breast metastasis.

CONCLUSION

Ovarian carcinoma usually presents with signs and symptoms related to the tumor burden within the abdominal cavity. The finding of isolated, distant metastases such as breast involvement without intraabdominal disease is extremely rare. Determining the origin of the primary tumor is important in directing the actual therapy.

Altered CD44 variant 6 expression in FIGO stage IB cervical carcinoma

OBJECTIVE

CD44 is an adhesion molecule which plays an important role in metastatic cascade by mediating tumor cell interaction with the endothelium and the subendothelial matrix. In this study CD44v6 expression was immunohistochemically investigated on 88 uterine cervical cancers. Correlation between expression and prognostic variables and the survival was examined.

METHODS

Eighty-eight patients with stage IB disease, treated primarily with surgery, were examined histopathologically and immunohistochemically. CD44v6 expressions of tumoral tissue and the nonneoplastic tissue nearby were examined using antiCD44v6 monoclonal antibody. CD44v6 expression was compared to the known clinicopathologic prognostic variables and survival of patients.

RESULTS

Nonneoplastic epithelium of the sections showed CD44v6 expression predominantly in basal and parabasal layers at least in traces. CD44v6 overexpression in neoplastic islands was evaluated as "general," "basal" (only in the basal portion of neoplastic islands), and "nonbasal" (also in the central portion of the neoplastic islands) separately. When expression and prognostic variables were compared, CD44v6 non-basal expression was found to be significant in nonsquamous cancers, when the tumor diameter was greater than 3 cm and in the tumors that showed recurrences. Univariate survival analysis with the Kaplan-Meier method showed that only the age of the patient is significantly correlated with disease-free survival. Interestingly when the same analysis was done for 5-year overall survival, diameter of the primary tumor, depth of cervical stromal invasion, existence and number of lymph node involvement, positivity for general CD44v6 expression, and positivity for nonbasal expression were found to be statistically significant. Furthermore multivariate analysis with Cox regression showed that nonbasal CD44v6 expression and lymph node involvement are independent variables for 5-year overall survival.

CONCLUSION

These results indicate that CD44v6 expression is associated with some of the important clinicopathologic prognostic variables and appears to be a predictor of advanced pathological-surgical stage of early clinical stage cervical carcinoma. CD44v6 nonbasal expression is significantly correlated with overall survival.

Feto-maternal morbidity and mortality after cardiac valve replacement

BACKGROUND

The aim of this study is to evaluate the fetomaternal morbidity and mortality of the pregnancies of women who conceived after cardiac valve replacement.

METHODS

A consecutive series of one hundred and thirty-six pregnancies of one hundred and one patients who conceived after cardiac valve replacement were retrospectively analyzed. Regarding the anticoagulation therapy, 101 patients were classified into three groups: A: patients on oral anticoagulants (n=68), B: patients on heparin (n=16) and C: patients who received no anticoagulation (n=17).

RESULTS

Three groups (patients on oral anticoagulants (A), on heparin (B), patients who received no anticoagulation (C)) were compared in terms of spontaneous abortion (19%, 11%, 5.6%), preterm delivery (14%, 22.3%, 16.6%), maternal mortality (3%, 11.1%, 0%), thromboembolic events (4%, 11.1%, 0%), cardiac failure (6%, 11.1%, 11.1%), atrial fibrillation (9%, 11.1%, 5.6%), antenatal bleeding (9%, 11.1%, 5.6%), delivery route and fetal malformation (5%, 0%, 0%) and no statistically significant differences were detected. In group B, hematoma formation rate (22.2%) (p=0.011) and transfusion rate (27.8%) (p=0.005) were significantly higher. Five cases of congenital anomalies were detected, all belonging to group A, but this tendency was not found to be statistically significant.

CONCLUSIONS

Management of pregnancies with prosthetic heart valves require closely monitored anticoagulation, and an obstetrician should be familiar with the potential fetal and maternal adverse effects of any anticoagulant therapy during the course of pregnancy.

Effects of hormone replacement on hemostasis in spontaneous menopause

OBJECTIVE

To examine the effects of continuous combined estrogen-progesterone replacement therapy on coagulation and natural anticoagulant systems in spontaneous menopause.

DESIGN

A randomized, double-blind, placebo-controlled study was conducted during a 6-month period to examine the effect of hormone replacement therapy (HRT) on blood coagulation parameters. One hundred-ten healthy postmenopausal women were randomized into two groups. Those in group 1 were given conjugated estrogen (0.625 mg/d, Premarin) and medroxyprogesterone acetate (5 mg/d, Farlutal), and those in group 2 were given identical tablets of placebo for 6 months. Serum levels of modified activated protein C resistance, antithrombin III, fibrinogen, factor VIIIa, factor VIII, factor IX, activated partial thromboplastin time, prothrombin time, thrombin time, and lipoprotein (a) were measured before and 6 months after the treatment and analyzed for changes in extrinsic and intrinsic coagulation parameters.

RESULTS

At the end of the 6-month period, fibrinogen, lipoprotein (a), and activated protein C resistance levels were decreased significantly in the HRT group compared with the control group. Antithrombin III levels were increased, indicating antithrombin activity. Activated partial thromboplastin time, as a measure for intrinsic coagulation cascade, was prolonged in concert with decreased intrinsic coagulation factors, factor VIII, and factor IX (p < 0.05). In the extrinsic coagulation system, prothrombin time was significantly increased, although factor VIIa level was not changed (p > 0.05).

CONCLUSION

Significant changes were observed in the coagulation parameters, which may further explain the cardioprotective effect of HRT.

Ovarian lymphomas. A clinicopathological analysis of 10 cases

Analysis of 10 cases of Non-Hodgkin's lymphoma with initial manifestation in the ovaries is presented with the histologic and immunohistochemical findings.

Intestinal testis tumor metastasis as a cause of intussusception: a case report

We report on an extraordinary testicular tumour causing intussusception with its intestinal metastases.

Epidermolysis bullosa acquisita: clinical manifestations, microscopic findings, and surgical periodontal therapy. A case report

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is an uncommon, acquired, chronic subepidermal bullous disease. This report describes a case of EBA with gingival involvement. A 43-year-old woman with EBA was referred to our clinic for periodontal therapy because of gingival tenderness and bleeding. She has been on cyclosporin A therapy for the last 2 years.

METHODS

Clinical findings were analyzed. Anterior gingivectomy operations were performed in 2 stages. The samples obtained during the surgery were examined using histopathologic, immunohistologic, and electronmicroscopic methods. Long-term effects of the surgical periodontal treatment on gingiva were evaluated both clinically and microscopically.

RESULTS

The dentition displayed minimal enamel hypoplasia. Decayed, missing, and filled surfaces score was found to be elevated. Periodontal examination showed generalized diffuse gingival inflammation and gingival enlargement localized mainly to the anterior region. Nikolsky's sign was positive. However, wound healing was uneventful after the operations. Microscopic findings were similar to those obtained from the skin. Twenty-one months after the operations, Nikolsky's sign was negative and no remarkable gingival inflammation was noted. Microscopic examination revealed that the blisters were fewer in number and smaller in size.

CONCLUSIONS

These results indicate that gingival tissues may also be involved in EBA. Uneventful wound healing after periodontal surgery in this case suggests that periodontal surgery can be performed in patients with EBA. Moreover, both our clinical and histopathologic findings imply that gingivectomy proves useful in maintaining gingival integrity in these patients. Our data may also suggest that the patients with EBA are highly likely to develop dental caries.

Overexpression of CD44 variant 6 in human endometrial cancer and its prognostic significance

OBJECTIVE

We evaluated the prognostic significance of CD44 isoform CD44 V6 in endometrial cancer.

METHOD

Immunohistochemistry was used to determine the expression of CD44 V6 in 78 randomly selected endometrial cancer specimens.

RESULTS

CD44 V6 was detected in 53% (41/78) of the tumor samples. Clinicopathological evaluation revealed an inverse correlation with CD44 V6 expression and conventional poor prognosticators such as lower segment involvement, nuclear and structural grade, myometrial invasion, serosal involvement, lymph-vascular space invasion, and adnexal metastasis. Furthermore, the CD44 V6-negative group was found to be associated have a higher recurrence rate and a shorter disease-free survival.

CONCLUSION

These findings indicate that absence of CD44 V6 expression in cases of endometrial cancer might be coupled with a more aggressive course.

nm23 Expression in choroidal melanoma

nm23 protein expression of choroidal melanoma was investigated to determine its relationship with clinical and histopathological characteristics of the tumour. Thirty-four consecutive choroidal melanoma patients were examined by immunohistochemistry. Although age, sex, tumour cell type, tumour size, pigmentation, necrosis, apoptosis and tumour lymphocytic infiltration were not correlated with nm23 protein expression, tumours with low percentages of nm23-positive cells revealed higher nuclear grades and predominant mitotic figures. nm23 may be associated with melanoma progression, but there is no proof that it plays a role in the metabolic process of the tumour.

The effect of age on proliferating cell nuclear antigen expression in oral gingival epithelium of healthy and inflamed human gingiva

BACKGROUND

Age-related changes in proliferative activity in human gingival epithelium are uncertain. Proliferating cell nuclear antigen (PCNA) is a nuclear protein associated with the cell cycle. Nuclear PCNA immunoreactivity is found in the proliferative compartment of normal tissues. The aims of this study were to investigate the localization of PCNA expression in oral gingival epithelium (OGE) and to define the age-related changes as to PCNA-proliferative index (PI) in inflamed as well as healthy gingiva. Mitotic index (MI) was also used as a conventional marker of cell proliferation. Additionally, the effect of aging upon the maximum epithelial thickness (MET) was determined.

METHODS

Twenty older (65 to 85 years) (study) and 20 middle-aged (35 to 45 years) (controls) subjects were included in the study. Biopsies were obtained both from healthy and inflamed gingiva. The expression of PCNA was evaluated in formalin-fixed, paraffin-embedded gingival samples using an immunoperoxidase technique and PC 10 monoclonal antibody to PCNA. Hematoxylin and eosin stained sections were used for the quantitative measurement of MI and MET.

RESULTS

All the tissue sections contained positive staining cells for PCNA in the gingival epithelium. Although PCNA expression was observed both in the basal and suprabasal layers, it was more prominent in the suprabasal layers. PI in inflamed gingiva was significantly higher in the older group. However, no significant difference was observed between the study and control groups with respect to PI in healthy gingiva. When all the subjects taken into the study were analyzed as a single group, PI in the inflamed gingival samples were found to be increased with aging. Nevertheless, no age-related change was noted in MI and MET. In both the study and the control groups, PI, MI, and MET were found to be increased due to inflammation.

CONCLUSIONS

Our data indicate that PCNA expression in inflamed gingiva is higher in older subjects. Furthermore, a significant correlation was noted between aging and PCNA expression in inflamed gingiva. As there is no increase in mucosal epithelial thickness despite increased proliferation, we speculate that the duration of the PCNA+ phase in cell cycle may be longer in older subjects. This study also implies that PCNA immunolocalization can be used as an index of the state of cell proliferation in both biological and pathological events of the gingiva and/or other mucosal tissues.

Cutaneous fixed drug eruption to paclitaxel; a case report

The aim of this report was to investigate an adverse effect of paclitaxel. Cutaneous fixed drug eruption against paclitaxel--which is rarely seen--is explained. A 70-year-old caucasian woman experienced three operations for ovarian carcinoma and finally a paclitaxel-based chemotherapy regimen was initiated as adjuvant chemotherapy. Following the administration of the first dose of paclitaxel, the patient had a cutaneous reaction that was clinically consistent with "fixed drug eruption". Lesions regressed with a topical steroid dressing. Histopathological examination of the lesion confirmed clinical diagnosis. It is interesting that such a reaction could occur despite the use of premedication with systemic corticosteroid antihistaminic prophylaxis yet heal rapidly with topical corticosteroid therapy. Thus we recommend careful observation for cutaneous side-effects in patients who receive paclitaxel or other taxanes, even with premedication prophylaxis.

Disseminated peritoneal leiomyomatosis. A benign entity mimicking carcinomatosis

Disseminated peritoneal leiomyomatosis (DPL) is a rare entity, occurring primarily in premenopausal women. The lesion is characterized by numerous subperitoneal nodules of benign smooth muscle proliferations which usually mimics the macroscopic appearance of the peritoneal carcinomatosis. We report a case of DPL and multiple uterine leiomyomas, occurring in a 50 year old premenopausal woman who was on oral contraceptives for the last three years. In order to diagnose this entity clinicians and pathologists have to be alert and collaborative during the intraoperative frozen section consultation.

Physical therapy in a patient with bilateral obturator nerve paralysis after surgery. A case report

Obturator nerve injury can result from surgical procedures. Bilateral obturator nerve injury developed in our patient as a result of edema in the obturator fossa after a debulking operation. In the postoperative period, neuromuscular electrical stimulation, electromyographic (EMG) biofeedback, exercise and a home treatment program were used as the physical therapy approach. The patient became symptom-free after the physiotherapy program.

Clinicopathological implication of cripto expression in early stage invasive cervical carcinomas

This study evaluates the expression of cripto (CR-1) protein in matched sets of non-neoplastic cervical epithelium, primary cervical carcinoma and metastatic tumours in the lymph nodes to investigate its role in uterine cervical cancer development and progression. Ninety-four primary cervical carcinomas in an early clinical stage and having the same surgical treatment modality were analysed. Immunoreactivity in the primary tumour was compared with that of non-neoplastic cervical epithelium and metastatic lymph nodes. The conventional clinicopathological prognostic variables for cervical carcinomas such as grade, tumour size, depth of invasion, parametrial and endometrial extension, lymphovascular space involvement and lymph node metastasis status were also compared with CR-1 expression of the primary tumour. Strong CR-1 immunopositivity was significantly correlated with tumour size and lymphovascular space involvement (P < 0.05). Furthermore, a significant relationship was found between CR-1 immunoreactivity and endometrial extension as well as parametrial involvement (P < 0.05). Interestingly, the CR-1 expression level was increased in metastatic lymph nodes compared with their primary tumours. These results suggest that CR-1 may contribute to disease progression in cervical carcinomas.