Fallopian tube cytology as a diagnostic tool for adnexal malignancy: the CytoSaLPs score

INTRODUCTION

During the past decade, the theory that high-grade extrauterine pelvic tumors originate from the fallopian tube has been strongly suggested. Our study aims to illuminate the possible role of tubal cytology as an accessory identification tool for gynecologic extrauterine malignancies, allowing in the long term the implementation of population-level cytologic tube evaluation during all benign gynecologic surgeries that do not result in salpingectomy.

MATERIALS AND METHODS

We ex vivo collect salpingeal epithelial cells from the fibria directly from fresh fallopian tube specimens from women undergoing salpingectomy for any indication. The cytomorphologic characteristics of the salpingeal cells are subsequently evaluated and categorized into malignant and non-malignant. Finally, the ipsilateral adnexa are examined with the SEE-FIM (Sectioning and Extensively Examining the FIMbriated End) protocol and the pathology reports are corelated with the cytologic findings. Our research protocol is ongoing and is designed to include a total of 300 patients in order to confirm the sensitivity and specificity of salpingeal cytology as a method in the early diagnosis of extrauterine gynecologic malignancies.

RESULTS

So far, we have obtained 343 salpingeal brushings from a total of 214 patients. The sensitivity of cytology regarding distinguishing malignant from non-malignant tumors is 69.64% (95% CI: 55.90%-81.22%), and its specificity 75.96% (95% CI: 70.59%-80.79%). Cytology's positive predictive value (PPV) is 16.33% (95% CI: 12.57%-20.67%), while the negative predictive value (NPP) reached 92.77% (95% CI: 89.56%-95.04%). In general, the diagnostic accuracy of the cytologic evaluation reaches 74.93% (95% CI: 66.99%-79.43%).

CONCLUSIONS

Salpingeal cytomorphologic evaluation appears to be a promising method for early detection of adnexal cancer.

Experience With J-Plasma Device in Achieving Complete Cytoreduction in Patients With Ovarian Cancer

BACKGROUND/AIM

Ovarian cancer remains one of the most lethal malignancies in women. Optimal surgical cytoreduction is the most important prognostic factor of survival in patients with advanced ovarian cancer. The helium gas plasma device (J-Plasma) has recently been introduced into surgical treatment of these patients with some promising results. The aim of this study was to evaluate the utility of J-Plasma in the debulking surgery of patients with ovarian cancer.

PATIENTS AND METHODS

A single center retrospective analysis of the characteristics of patients with ovarian cancer who had cytoreductive surgery with the use of J-Plasma device from January of 2020 until July of 2022 was conducted.

RESULTS

A total of 13 patients were included in our study. Six patients were treated with primary debulking surgery, whereas seven underwent interval debulking surgery after neoadjuvant chemotherapy. Complete cytoreduction was achieved in nine patients (64%), and CC-1 in four patients. Most of the patients did not face any major complications; only 1 patient suffered from small bowel fistula that needed relaparotomy.

CONCLUSION

J-Plasma can safely be used in ovarian cancer debulking surgeries performed by gynecologic oncologists in tertiary centres. This technology can safely increase the complete cytoreduction rates.

The Utility of Fallopian Tube Cytology in the Early Detection of Extrauterine Serous Gynecological Malignancies: A Narrative Literature Review

INTRODUCTION

The aim of the study was to analyze the published evidence for the use of fallopian tube brush cytology for the early detection of extrauterine serous gynecological cancer.

METHODS

We systematically searched the literature and, additionally, cross-checked on the bibliographies of selected articles. The inclusion criteria involved studies assessing the utility of fallopian tube brush cytology and its applications in the diagnosis, screening, or follow-up of extrauterine serous gynecological cancer.

RESULTS

The search strategy resulted in 21 abstracts or full-text articles, 5 of which met the inclusion criteria. The year of publication ranged from 2016 to 2022, and a total of 193 fallopian tube samples were investigated. Cytobrush, Tubebrush©, and Cytuity™ were used to obtain salpingeal samples for liquid-based cytology evaluation.

CONCLUSIONS

Our findings indicate that, at present, there is a lack of satisfying evidence-based data in the literature which would support the implementation of fallopian tube brush cytology as an adjunctive tool for early detection of extrauterine serous gynecological cancer. Thus, we believe that there is need for well-designed clinical studies to assess the effectiveness and diagnostic accuracy of the method as well as to validate the cytological criteria for the diagnosis and prediction of gynecological malignancies.

Follow the River to the Lake: Sentinel Lymph Node Identification Using the Robotic Platform in Endometrial Cancer Patients

Sentinel lymph node biopsy for the management of endometrial cancer patients has been introduced into surgical staging of these patients. Several articles and guidelines have evaluated and found sentinel lymph node biopsy as an efficient and oncological safe procedure. The aim of this article is to highlight the most important tips and tricks in order to optimize sentinel lymph node identification and dissection based on our experience. Each step of sentinel lymph node identification technique is analyzed. Tips and tricks, such as site and time of indocyanine green dye injection are essential in optimal identification of sentinel lymph node in patients with endometrial cancer. The standardization of the technique and the recognition of anatomic landmarks are essential as they lead to an improved and effective identification of sentinel lymph node.

Does Obesity Forbid Robotic Gynecological Surgeries? An Urban Legend

Introduction: Obesity is a worldwide problem that considered to be a challenge in optimal surgical management. A breakthrough in the technologies of minimal invasive surgery over the last ten years has turned robotic approach into the widespread method for surgical management of obese population. Aim: In this study we emphasize the benefits of the robotic assisted laparoscopy versus open laparotomy and conventional laparoscopy in obese women with gynecological disorders. Methods: We conducted a single center experience retrospective study of obese women (BMI 30 Kg/m2) that underwent robotic assisted gynecologic procedures from January 2020 till January 2023. "Iavazzo" score was used in order to predict preoperatively the feasibility of robotic approach as well as the overall operative time. The perioperative management a well as the postoperative course of obese patients were documented and analyzed. Results: 93 obese women underwent robotic surgical management for benign and malignant gynecological disorders. 62 of these women had BMI between 30 and 35 kg/m2 and 31 had BMI 35 kg/m2. None of them was converted into laparotomy. All of the patients had a smooth postoperative course without any complications and were discharged at the first postoperative day. Mean operative time was 150 min. Conclusions: Our 3-year experience in robotic-assisted gynecologic surgery in obese patients has revealed numerous benefits concerning perioperative management and postoperative rehabilitation.

Vaginal Evisceration After Abdominal Hysterectomy: A Case Report

Vaginal cuff dehiscence (VCD) is an extremely rare complication after a hysterectomy, with possible life-threatening consequences. Multiple cases of pelvic organ evisceration through the vaginal cuff have been reported, most frequently precipitated by sexual intercourse. Surgeons should be suspicious of clinical signs of VCD postoperatively, as any intervention should be prompt. Patients at high-risk patients of developing vaginal cuff dehiscence should be advised to refrain from straining exercises for longer periods of time. Herein, we present the case of a 46-year-old with this complication.

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer

OBJECTIVE

To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer.

METHODS

In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort.

RESULTS

A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy.

CONCLUSIONS

Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

Uterine angiolipoleiomyoma. A case report and systematic literature review

Uterine angiolipoleiomyomas are rare, benign mixed mesenchymal lesions. A manifestation in the gynecological region is quite uncommon, with few cases described in the literature so far. We present an interesting case of a 59-year-old woman diagnosed with uterine angiolipoleiomyoma, and the results of the conducted systematic review of the literature. The patient presented with a pelvic mass masquerading as a leiomyoma on the ultrasound and postmenopausal vaginal bleeding. At laparotomy, a large uterus was noticed and the histopathology set the diagnosis of angiolipoleiomyoma. Immunohistochemistry revealed negativity for Melan-A and HMB-45 melanoma-specific antibodies and positivity for Van Gieson and orcein histochemical stains.

We systematically reviewed the literature. The eligible articles were those written in English, excluding animal studies and studies reporting angiolipoleiomyomas in other regions beside the uterus. The present case is one of the 10 cases of uterine angiolipoleiomyoma reported in the literature. In 8 out of 11 (72.7%) cases, uterine angiolipoleiomyomas arose from the corpus of the uterus, while in 2 (18.1%) cases they were located at the cervix, and in one case (9%) angiolipoleiomyoma was located in the broad ligament. Concerning symptoms, four of the patients (36.4%) presented with abdominal and pelvic pain, two (18.1%) with postmenopausal vaginal bleeding, one with menometrorrhagia (9%), and one with uterine prolapse and cystocele (9%). Immunohistochemical staining of uterine angiolipoleiomyomas was positive for SMA in 4 patients (36.4%), positive for desmin in 3 cases (27.3%), positive for anti-S-100 protein antibody in 2 patients (18.1%), while in one case (9%) immunopositivity was observed for CD31. Only our case (9%) was also tested for CD34, Van Gieson and orcein, the first of these being negative and the other two positive (at the blood vessels in a specialized pattern). Three of the patients (27.3%) were also tested for HMB-45 and all three were immunonegative.

In order to establish the diagnosis of uterine angiolipoleiomyomas, ultrasonography and additional MRI may help the preoperative prediction of a benign mass. Immunohistochemistry will show strong positivity of alpha-smooth muscle actin and desmin. Complete abdominal hysterectomy is the preferable treatment.

Crohn’s Disease of the Vulva: a Case Report

Crohn&rsquo;s disease is a multi-systemic chronic inflammatory disease that can affect various organs besides the gastrointestinal tract such as joints, uvea, and the skin. Vulvar Crohn&rsquo;s disease is a rare entity occurring with vulvar lesions that show typical Crohn&rsquo;s disease granulomatous inflammation but are not contiguous with the gastrointestinal involvement. Vulvar Crohn&rsquo;s disease can be easily confused with other granulomatous diseases and awareness that such involvement may precede gastrointestinal symptoms must be raised. Few cases of vulvar Crohn&rsquo;s disease have been reported in the literature to date. Here, we report a case of a 43-year-old woman with a 6-month history of a vulvar lesion; the patient was diagnosed with Crohn&rsquo;s disease of the large bowel just over a year ago.

Sarcomatoid Squamous Cell Carcinoma Of The Vulva:A Case Report

Background

A sarcomatoid squamous cell carcinoma of the vul-va is a very rare malignancy of the female genital tract . It has been characterized as an aggressive disease typically associated with early development of local recurrences as well as distant metastases.

Case

A 77-year old woman presented to our hospital with an aggravated vulvar mass, complaining about pruritus and pain. The patient underwent a radical vulvectomy with bilateral inguinal lymph node dissection and bilateral pelvic lymph node sampling. The histo-pathologic examination was consistent with a sarcomatoid squamous cell carcinoma of the vulva with an identical microscopic and im-munohistochemical appearance. The FIGO stage was IB and further management was decided to be radiotherapy.

Conclusion

A sarcomatoid squamous cell carcinoma is a rare entity with an aggressive biological behavior. To date, there have been only a few cases of the disease reported in the literature. Therefore a more systematic collection and closer study of such cases would be helpful for achieving an early diagnosis and more effective therapeutic strategies in the future.

Primary Peritoneal Serous Carcinoma Detected by Abnormal Cervical Smear: a Case Report

Primary peritoneal serous carcinoma (PPSC) is a rare malignancy, the clinical characteristics of which resemble ovarian serous carcinoma. We present a rare case of PPSC detected by an abnormal cervical smear, the first one with an absence of ovarian tissue at the time of the initial diagnosis.

A 59-year-old asymptomatic woman presented with glandular atypia on routine Papanicolaou smear. Endocervical and endometrial curettage showed an adenocarcinoma with focal squamous differentiation and uncertain further classification. The patient had a past surgical history of bilateral salpingoophorectomy due to endometriosis. Abdominal MRI depicted omental multinodularity, great amount of ascites and possible endometrial tumor. The patient underwent total hysterectomy, omentectomy and biopsies of implants on Douglass pouch. &nbsp;Surgical and histological findings were consistent with primary peritoneal serous carcinoma.&nbsp;

Abnormal pap smear could rarely be suggestive of extrauterine malignancies, such as peritoneal cancer.

Concurrent gynecologic surgery and panniculectomy in morbidly obese women with gynecologic cancer, a single-center experience

PURPOSE

As the prevalence of obesity has been rising during the past decades worldwide and especially in Greece, surgeons have faced significant challenges concerning the treatment of morbidly obese women with gynecologic cancer. Panniculectomy is a safe procedure that offers better visualization of pelvic anatomy and prevention of major complications in these women.

METHODS

Aim of this study is to describe a single-center experience of surgical treatment of morbidly obese women with gynecologic cancer and concurrent panniculectomy. We, also, review the literature for articles that report concurrent gynecologic surgery and panniculectomy, to summarize the complications that were encountered.

RESULTS

From 2015 to 2018, 38 obese women were treated with concurrent panniculectomy at the time of gynecologic surgery for cancer in a single institution. Median age was 55.62 years old, median BMI 43.79 kg/m², median blood loss 243.75 ml and median operative time approximately 200 min. Twenty-nine patients had endometrial cancer, one patient had concurrent endometrial cancer and fallopian tube cancer, six patients had borderline ovarian cancer, and two had adult granulosa ovarian tumour. Intraoperative and postoperative complications were documented. Five patients suffered from wound infection and were treated with antibiotics and one patient died after wound infection, wound dehiscence, and renal failure.

CONCLUSION

For selected obese patients, concurrent panniculectomy with surgical treatment of gynecological cancer is a safe and efficient procedure.

An Alternative Treatment for Vaginal Cuff Wart: a Case Report

Human papillomavirus (HPV) has been directly related to acuminate warts and cervical cancer, the second most common neoplasia among women. Given the lack of treatment against the virus itself, many medications have been utilised, mainly aiming in modifying the host's immunological response. We present the case of a 54 years old postmenopausal patient with a history of vaginal cuff wart and HPV persistence that we managed in our clinic for 6 months with a mix of curcumin, aloe vera, amla and other natural ingredients. As the patient was found to be intolerant to imiquimod (one of the most common conservative methods of treatment) we attempted the use of curcumin, which was applied to the area of the wart three times per week for 6 months. Both clinical and colposcopical improvement was noted in regular clinic visits with regression of the lesion. The outcome of this case encourages our view that curcumin should be considered as a significant treatment modality against HPV infection and acuminate warts.

Safety and efficacy of synchronous panniculectomy and endometrial cancer surgery in obese patients: a systematic review of the literature and meta-analysis of postoperative complications

Panniculectomy combined with gynaecological surgery constitutes an alternative approach for endometrial cancer (EC) in obese patients. The present study aimed to assess the current knowledge concerning the safety and efficacy of combining panniculectomy in surgical management of EC. Four electronic databases were systematically searched for articles published up to May 2019. A total of five studies, of which two were non-comparative and three comparative, were included. Meta-analysis of complications among panniculectomy and conventional laparotomy group revealed no difference in either intra- or post-operative complication rates. Moreover, no difference was reported in surgical site complications (p=0.59), while wound breakdown rates were significantly elevated in the laparotomy group (p=0.02). Panniculectomy combined surgery for the management of EC appears to be a safe procedure and results in comparable outcomes compared with conventional laparotomy with regard to complications and improved wound breakdown rates.

Primary peritoneal serous papillary carcinoma: a case series

PURPOSE

To present the clinical and laboratory characteristics, as well as the management, of patients with primary peritoneal serous papillary carcinoma (PPSPC).

METHODS

This is a retrospective study of 19 patients with PPSPC who underwent debulking surgery followed by first line chemotherapy and were managed in Metaxa Memorial Cancer Hospital between January 2002 and December 2017.

RESULTS

The median age of the patients was found to be 66 years (range 44-76 years). Clinical presentation of PPSPC included abdominal distention and pain, constipation, as well as loss of appetite and weight gain. Two of the patients did not mention any symptomatology and the disease was suspected by an abnormal cervical smear and elevated CA125 levels respectively. Biomarkers measurement during the initial management of the patients revealed abnormal values of CA125 for all the participants (median value 565 U/ml). Human epididymis secretory protein 4 (HE4) and ratios of blood count were also measured. Perioperative Peritoneal Cancer Index ranged from 6 to 20. Optimal debulking was achieved in 5 cases. All patients were staged as IIIC and IVA PPSPC and received standard chemotherapy with paclitaxel and carboplatin, whereas bevacizumab was added in the 5 most recent cases. Median overall survival was 29 months.

CONCLUSION

PPSPC is a rare malignancy, the management of which should take place in tertiary oncology centers.

Abdominal radical trachelectomy during pregnancy: A systematic review of the literature

BACKGROUND

Lack of large trials or randomized studies characterize any type of treatment for cervical cancer during pregnancy experimental.

OBJECTIVE

To accumulate the existing evidence on abdominal radical trachelectomy (ART) during pregnancy.

SEARCH STRATEGY

Medline, Scopus and Google Scholar databases were thoroughly searched up to September 2018 for relevant studies in this field using the terms "Radical Trachelectomy", "Pregnancy", "Cervical cancer", "fertility sparring".

SELECTION CRITERIA

Observational studies and case reports which addressed cases of pregnant women who underwent ART for cervical cancer during pregnancy were included.

MAIN RESULTS

A total of ten studies which recruited 19 patients were finally included. At the time of ART, the gestational age of patients ranged from 7th to 22th weeks. Mean operative time of ART was 351.8 min while mean blood loss was 1,040.35 ml and 5 patients (50%) received blood transfusion. Fetal loss rate was 21.1% (n = 4) and from the completed deliveries 7 (46,66%) were preterm. Postoperative maternal related complication rate was 23.1% (n = 3/13). The mean follow-up was 16.89 months (SD 12.69), whereas all cases were free of disease without evidence of recurrence during their follow-up.

CONCLUSIONS

According to the existing evidence, ART may be a tolerable option for pregnant women with early-stage cervical cancer with acceptable oncological and obstetrical outcomes. Future multicenter randomized trials are of particular importance to elucidate the optimal treatment option.

Radical abdominal trachelectomy and pelvic lymphadenectomy in a nulliparous patient with cervical adenocarcinoma: A case report

Cancer of the cervix is the fourth most common malignancy among women in the world and the sixth most common among women in Europe. Almost half of patients with an early-stage invasive cervical carcinoma are under 40 years of age, while the average age at first pregnancy in European countries is over 28 years. Therefore many women with cervical cancer have not started or completed their family at the time of diagnosis and ask for fertility-sparing surgery. Radical trachelectomy is a safe alternative to standard care (radical hysterectomy) for patients diagnosed with early-stage cervical cancer and is a reasonable choice in well selected cases. We present the case of a 23-year-old patient diagnosed with a cervical adenocarcinoma and treated with abdominal trachelectomy.

•

Cervical cancer is currently the fourth most common female malignancy in the world

•

Almost half of the patients with an early stage disease are under 40 years old.

•

The average age of first pregnancy in European countries is above 28 years old.

•

Radical trachelectomy (RT) is a safe and appropriate fertility sparing procedure.

•

We report a case of a young patient managed with radical abdominal trachelectomy.

Is fertility sparing surgery a treatment option for young patients with yolk sac tumor?

Yolk sac tumor (YST) is the third most frequent ovarian germ cell type ovarian tumor. YST occurs primarily in young girls and in women at reproductive age and thus, the preservation of fertility is considered to be a crucial option if possible for these patients. Compared to previous years, the use of innovative chemotherapeutic regimens in the treatment of YSTs improved significantly the prognosis and outcomes of this rare type of neoplasia. As YSTs are chemosensitive, this fact favors fertility sparing surgical approach and less aggressive type of operations. We present a narrative review of the multispecialty fertility sparing surgical and medical approach of women with YST.

Fertility sparing approach as the standard of care in young patients with immature teratomas

Immature teratomas are quite rare tumors arising in young women. They are usually diagnosed in early stage and grade and have a good prognosis. In these young patients, fertility-sparing management is suggested as the standard of care. Bilateral immature teratoma is a rare condition with an incidence of 10%, with a five-year survival rate of 80%. The majority of patients received fertility-sparing treatment followed by adjuvant chemotherapy in 78%. Older age, advanced stage, and high grade are negative prognostic factors. The surgery-only, watch-and-wait approach was evaluated; however, after a median follow-up time of 42 months, 50% of patients experienced recurrence, but they were successfully salvaged with chemotherapy. In a retrospective study, 12 out of 27 patients tried to conceive, resulting in 10 pregnancies (8 after chemotherapy). We present a narrative review of the current literature regarding the essential multidisciplinary approach of such patients in order to achieve the best oncologic and fertility-sparing outcome.

Is fertility sparing surgery a treatment option for premenopausal patients with dysgerminoma?

Dysgerminoma is the most common ovarian germ cell type ovarian tumour. Primarily, it presents in young women at reproductive age and thus, the preservation of fertility is considered to be fundamental when it is possible for these patients. In comparison to the past the restriction of the extent of the surgical procedure as well as the introduction of innovative chemotherapeutic regimens improved significantly both, the prognosis and the clinical outcomes of this rare neoplasia. As dysgerminomas are extremely radio- and chemosensitive, fertility sparing approach and less aggressive operations should be favoured. We present a narrative review of the multispecialty fertility sparing surgical and medical approach for women with dysgerminoma (Ref. 21).

Uterobrush method in the detection of endometrial pathology

BACKGROUND

Endometrial brush cytology is a widely accepted method for the detection of endometrial lesions. The aim of this study was to evaluate the role of cytological sampling using Uterobrush in the screening of endometrial pathology.

PATIENTS AND METHODS

This is a prospective double-blind study evaluating the efficacy of the Uterobrush method (Cooper Surgical, Trumbull, USA) in the detection of endometrial abnormalities. Endometrial cytology was performed during the period January 2009 to April 2010 in all symptomatic patients that underwent dilatation and curettage. The collected samples were firstly smeared directly onto a glassslide and consequently into Thin-Prep buffer. Cytologic features were evaluated according to the criteria of Tao. The main objective was to evaluate the efficacy of Uterobrush method comparing the results of cytologic and histopathologic examination.

RESULTS

The sample of the study consisted of 100 women aged 55.8 years (range 38-78 years) with recorded data regarding Uterobrush test and classic histologic examination. Fifty-five patients were postmenopausal. A total of 92% of the samplings were performed by trainees. Endometrial carcinoma was cytologically diagnosed in 8/9 patients, whereas endometrial polyps were diagnosed in 5/34 patients (14.7%). All the patients with simple hyperplasia were correctly diagnosed with the Uterobrush method, whereas the diagnosis of complex hyperplasia with or without atypia was correct in 85.7% and 100% of patients, respectively. Regarding endometrial carcinoma, the sensitivity, specificity, positive and negative predictive values were 88.9%, 100%, 100% and 98.9%, respectively. On the other hand, regarding endometrial polyps, the sensitivity, specificity, positive and negative predictive values were 14.7%, 100%, 100% and 69.5%, respectively.

CONCLUSION

Uterobrush is a reliable direct intrauterine sampling for detecting endometrial abnormalities especially endometrial carcinoma and hyperplasia, but not endometrial polyps. It is a well-tolerated, easy to use method, which provides generous endometrial sampling without contamination from the endocervix or the vagina.

Paclitaxel-ifosfamide-carboplatin combination chemotherapy regimen in advanced uterine and adnexal malignant mixed Mullerian tumours

Background:

Malignant mixed Mullerian tumours (MMMTs) of the uterus and adnexa represent aggressive gynaecologic malignancies with a high rate of loco-regional and distant failure. For that reason, we evaluated the paclitaxel–ifosfamide–carboplatin (TICb) combination in patients with advanced MMMTs.

Methods:

Female patients with advanced MMMTs, WHO-PS 0–2, no prior chemotherapy for systemic disease, unimpaired haemopoietic and organ function were eligible. Chemotherapy was administered at the following doses; paclitaxel: 175 mg m^–2 on day 1, ifosfamide: 2.0g m^–2 day^–1 – days 1 and 2, and carboplatin at a target area under the curve 5 on day 2, with prophylactic G-CSF from day 3.

Results:

Forty patients of a median age 61 (45–72) years, performance status 0–2 with advanced MMMTs of the uterus (n=34), tubes (n=2) or ovary (n=4) have entered and all were evaluable for response and toxicity. Responses were as follows: 27 out of 40 (67.5%) evaluable patients responded, with 11 complete responses and 16 partial responses, while 10 had stable disease, and 3 developed progressive disease. The median response duration was 9 months (range, 4–40 months), median progression-free survival 13 months (range, 3–42 months), while median overall survival 18 months (range, 4–48 months). Grade 3/4 neutropenia was recorded in 22 out of 40 (55%) – with 13 developing grade 4 (⩽7 days) and 7 out of 40 (17.5%) of patients at least one episode of febrile neutropenia.

Conclusion:

In this study, it appears that the TICb combination, yielded important activity with manageable toxicity in females with advanced MMMTs warranting further randomised comparison with current standard regimens.

Quantitative analysis of heparanase gene expression in normal cervical, cervical intraepithelial neoplastic, and cervical carcinoma tissues

Heparanase is an endoglycosidase that specifically cleaves heparan sulfate side chains of heparan sulfate proteoglycans, the major proteoglycans in the extracellular matrix and cell surfaces. Traditionally, heparanase activity was implicated in cellular invasion associated with angiogenesis, inflammation, and cancer metastasis. More recently, heparanase up-regulation was documented in an increasing number of primary human tumors. Iotan this study, we sought to investigate the expression of heparanase messenger RNA (mRNA) in normal cervical tissue and intraepithelial cervical lesion and its clinicopathologic importance in invasive cervical cancer. Gene expression of heparanase was assessed by quantitative real-time reverse transcriptase polymerase chain reaction in 28 normal cervical, 26 intraepithelial neoplastic, and 48 cervical cancer tissue samples. Heparanase mRNA expression was different between the 3 groups and lower in normal cervical specimens in relationship with intraepithelial cervical lesions and invasive cervical cancer tissue samples (P = 0.048). Gradually increasing expression of heparanase was evident as the cells progressed from low-grade to high-grade squamous intraepithelial lesions (P = 0.002). In invasive cervical cancer cases, there was a direct correlation between heparanase expression and tumor size (P = 0.002). In cases treated with radical hysterectomy and pelvic lymphadenectomy, the heparanase mRNA expression was significantly higher in tumors exhibiting lymph vascular space invasion (P = 0.044) and in cases with big tumor size (P = 0.005). In our study, we did not find any significant correlation between disease-free and overall survival rates and expression of heparanase (P = 0.396 and P = 0.712, respectively). The results of this study suggest that the gene expression of heparanase in cervical cancer enhances growth, invasion, and angiogenesis of the tumor and may have therapeutic applications.

Clinical value of preoperative lymphoscintigraphy in patients with early cervical cancer considered for intraoperative lymphatic mapping

The purpose of this study was to examine the clinical usefulness of preoperative lymphoscintigraphy (PLS) for sentinel node identification in patients undergoing lymphatic mapping during surgery for early cervical cancer.

PATIENTS AND METHODS

Day-before PLS was performed in 42 patients who were candidates for open radical hysterectomy and intraoperative lymphatic mapping, using a combination of radiocolloid and blue dye technique.

RESULTS

In 39 patients, at least one sentinel node (SN) was evident either in the lymphoscintigram or during the operation (detection rate 92.8%). Lymphoscintigraphy revealed unilateral SNs in 24 (61.5%) cases and bilateral SNs in 15 (38.5%). A total of 56 SNs were identified. Intraoperatively, 5 out of 24 patients with unilateral SNs on PLS had bilateral identification. The total number of SNs retrieved was 103 (2.6/patient). While one SN was identified in 25 cases on PLS, 32 patients had two or more SNs intraoperatively. The agreement between preoperative and intraoperative detection regarding laterality, number and location of SNs was poor (Kappa<0.69).

CONCLUSION

PLS is of limited clinical value for intraoperative SN detection in early cervical cancer.

Paclitaxel (T), ifosfamide (I), and carboplatin (Cb) (TICb) combination chemotherapy in advanced uterine and adnexal malignant mixed mullerian tumors (MMMTs)

5517

Background: Malignant mixed mullerian tumors (MMMTs) of the uterus and adnexa represent aggressive gynecologic malignancies with a high rate of locoregional and distant failure. For that reason we evaluated the TICb combination in patients with advanced MMMTs. Methods: Patients with advanced MMMTs [stages III-IV and relapses after surgery (Sx)±RT], WHO-PS 0–2, no prior chemotherapy, unimpaired hematopoietic/organ function were eligible. Chemotherapy was administered as follows; T: 175 mg/m2 d1, I: 2.0 g/m2/d-d1+2, and Cb at a target AUC = 5 (according to creatinine clearance based on Calvert's formula) on d2 after I. G-CSF was administered from day 3–7. Results: Thirty-two patients with MMMTs of the uterus (n = 28), tubes (n = 2), or ovary (n = 2) have entered so far and all are evaluable for response and toxicity: median age = 61 (45–72), PS = 1 (0–1), stages; III = 18 (56%), IV = 14 (44%), histologies were; with homologous sarcoma component: 21, with heterologous component: 11. Prior treatment for locoregional disease included Sx: 23, Sx+RT: 9. Disease sites at diagnosis included: pelvic disease 12; pelvic/paraortic lymph nodes 14; peritoneal implants 16; liver 4; lung nodules 9; bone metastases 1; malignant pleural effusion 4. Responses were as follows: 21/32 (66%) evaluable patients responded, with 9 complete responses (CR) and 12 partial responses (PR), while 8 had stable disease (SD), and 3 developed progressive disease (PD). The median response duration was 8 mo (4–28), median time-to-progression (TTP) 12.5mo (4–26), while median overall survival (OS) has not been reached yet since most patients receive second-line therapy. Grade (Gr) 3/4 toxicities included: neutropenia 18/32 (56%)-with 11 developing Gr4 (≤7 days) and 19% of patients at least one episode of febrile neutropenia managed successfully by broad spectrum antibiotics, thrombocytopenia Gr3: 5/32 (16%) and Gr4 3/32 (9%), no Gr3 neuropathy, Gr1 CNS toxicity in 1, no renal toxicity, 15 Gr2 myalgias, and 4 Gr3 vomiting. Conclusions: In the present study, it appears that the TICb combination, yielded important activity with acceptable toxicity in females with advanced MMMTs.

No significant financial relationships to disclose.

The sentinel node in cervical cancer patients: role of tumor size and invasion of lymphatic vascular space

BACKGROUND

The sentinel lymph node (SLN) technique aims at predicting the absence of regional nodal metastasis and seems promising in the management of cervical cancer patients.

PATIENTS AND METHODS

Forty patients undergoing surgery for early cervical cancer were submitted to the SLN procedure, using Blue Patente alone in 3, radiocolloid injection alone in 4 and both methods in 33 (82.5%). All patients underwent radical hysterectomy and pelvic lymphadenectomy.

RESULTS

The detection rate was as follows: overall 85%, blue dye alone 66%, radiocolloid alone 75%, dual method 87%. Detection was successful in 34 patients, with one false-negative result. No micrometastases were demonstrated during ultrastaging of the sentinels. The detection rate was higher in tumors <2 cm (94.1%) than in larger tumors (78.2%, p>0.09). Significant negative correlation between lymphatic vascular space invasion (LVSI) and detection rate was found (p<0.001).

CONCLUSION

SLN detection is feasible in early cervical cancer but presence of LVSI and a tumor size >2 cm negatively affect the detection rate and may increase the incidence of false negatives.

Evaluation of the possible benefits of post-radiotherapy surgery after concomitant chemoradiotherapy with a new radio-sensitizing regimen (irinotecan / CPT-11, interferon A2b and amifostine) for advanced-stage cervical carcinoma. Preliminary results of a pilot phase-II study

PURPOSE

This phase II pilot study was conducted to evaluate the results of a three-modality approach (which included post-chemoradiotherapy surgery) in advanced-stage cervical carcinomas.

PATIENTS AND METHODS

Thirty-six patients underwent either surgery or were put on follow-up after having received radical cervical radiotherapy (RT) combined with radiosensitizing chemoimmunotherapy with irinotecan (CPT-11), interferon (IFN) A2b, and amifostine. The last selection (surgery or follow-up) was based on clinical evaluation (downstaged or not). Feasibility, morbidity, surgical outcome and survival were evaluated.

RESULTS

Twenty-six patients had stage IIb and 10 IIIb disease at diagnosis. Sixteen (44%) were clinically downstaged, thus becoming eligible for surgery. Twelve (33%) were operated and the others were put on follow-up. There was no significant increase in treatment-related morbidity of the group of patients receiving three-modality therapy, since only one intraoperative complication had occurred. In 58% of the operated patients, chemoradiotherapy-resistant tumor was found on pathology of the cervical specimens, while 29% of them had lymph nodes infiltrated by the tumor. After a median follow-up of 42.5 months, overall survival (OS) of operated vs. non-operated patients (88 vs. 56%, respectively) show only a trend toward significance (p=0.10). The overall recurrence/metastasis rate was 36.1% and the disease-free survival (DFS) 56% for operated vs. 76% for non-operated patients, respectively (p=0.63).

CONCLUSION

These results indicate that post-chemoradiotherapy surgery is justified because of the high rate of residual disease found. Morbidity can be effectively limited with proper patient selection. A considerable survival benefit is expected, although this remains to be confirmed with phase III studies.

A two eterochronous primary gynaecological malignancies of different origin

AIM

The objective of our study is to present a rare case of two eterochronous primary gynaecological malignancies.

CASE

A 65-year-old para-2, white obese female, presented in our department 4 years ago, due to a single event of vaginal spotting. Curettage revealed an endometrial cancer. A total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Histology showed an endometrioid adenocarcinoma of endometrium stage Ib, moderately differentiated. No additional therapy was given. Twenty seven months later, a pathologic Papanicolaou smear came out on her routine follow-up. Although, recurrence on vaginal cuff was possible, the biopsies of anterior vaginal wall showed a poorly differentiated squamous cell carcinoma of the vagina. An exploratory laparotomy was performed, but tumor resection was not possible. The patient was classified as stage II vaginal carcinoma and underwent complete radiotherapy and chemotherapy.

CONCLUSION

This case indicates that female genital carcinomas of different histological origins may occur with minimal time-interval, even in the absence of known predisposing factors like previous chemo-radiotherapy, HPV infection or diethylstilbestrol exposure. The role of close follow up of hysterectomised patients should also be mentioned (Fig. 1, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Late struma ovarii diagnosis many years after total thyroidectomy. A rare entity

We present the case of a 53-year-old lady with incidental diagnosis of struma ovarii 10 years after total thyroidectomy due to papillary thyroid carcinoma. The disease was diagnosed owing to high levels of serum thyroglobulin. The patient underwent exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy. Close follow-up was proposed and her prognosis is excellent.

Primary peritoneal serous papillary carcinoma: clinical and laboratory characteristics

BACKGROUND

Primary peritoneal papillary serous carcinoma (PPPSC) is an uncommon primary malignancy of the peritoneum. The aim of our study is to present the characteristics of such a rare entity through our case series.

METHOD

This is a retrospective study of nine cases of PPPSC who were treated between January 2002 and April 2007 in METAXA Memorial Cancer Hospital, Piraeus, Greece. Medical files and histopathological diagnosis of each patient were retrospectively studied.

RESULTS

The median age of the patients was 63 years ranging from 44 up to 74 years. Clinically PPPSC presented with general abdominal discomfort in all of the patients. Three out of nine patients presented with constipation, 5/9 with distention, and 7/9 with ascites. All of the patients referred loss of appetite with weight gaining due to ascites. All the patients had pathological values of CA125 (over 35 U/ml) ranging from 125 up to 1,255 U/ml with median value 565 U/ml. Optimal debulking was possible in 3/9 of patients who were consequently treated with standard taxol-platin chemotherapy. Complete response was achieved in one woman. The median disease-free survival was 7 months and the median overall survival rate was 2.5 years.

CONCLUSION

PPPSC mimics ovarian papillary serous carcinoma regarding the clinical and laboratory characteristics but it has worse prognosis.

Laparoscopic pelvic exenteration: a new option in the surgical treatment of locally advanced and recurrent cervical carcinoma

Pelvic exenteration is an option in the treatment of persistent or recurrent cervical carcinomas confined to the central pelvis. The improvement of laparoscopic techniques and equipment in combination with broader experience of surgeons in laparoscopy made laparoscopic pelvic exenteration possible. This article reviews present experience with pelvic exenteration and analyses the advantages and disadvantages of the method compared to classical method (Tab. 2, Ref. 10).

The histological outcome of glandular dyskaryosis--AGUS--reported in Papanicolaou smears

PURPOSE

The objective of this study was to investigate the prognostic significance of glandular dyskaryosis/AGUS, reported in Papanicolaou (Pap) smears.

MATERIALS AND METHODS

During a 4-year period 26,408 smears were assessed at the Department of Cytology of our hospital. Thirty (0.11%) smears were reported as having glandular dyskaryosis. The studied material was taken by colposcopy, fractional curettage and/or cone biopsy.

RESULTS

The final diagnosis included 2 cases of invasive cervical carcinoma (1 squamous cell and 1 adenocarcinoma), 1 case with ovarian cancer, 8 cases with high grade squamous intraepithelial lesion (HGSIL) and 10 cases with other nonmalignant pathology (polyps, hyperplasia) of endometrial origin. These findings reflect a 36.7% positive predictive value for significant squamous and glandular pathology.

CONCLUSION

Patients with glandular dyskaryosis require further evaluation because it may hide serious pathology from all internal genital organs. Colposcopy in combination with fractional curettage and/or cone biopsy are proposed as the appropriate diagnostic tools in women with such cytological abnormality.

Accidential detection of salpinx carcinoma after omphalocele repair

BACKGROUND

Carcinoma of the fallopian tube is a rare disease accounting for < 1% of all gynecologic malignancies.

CASE

We present the first case of an accidental diagnosis of fallopian tube carcinoma after omphalocele repair.

CONCLUSION

Between 9 to 14% of cases are incidental findings during the work-up or exploratory laparotomy. A review of the literature regarding predisposing factors, histology, clinical and ultrasound appearance, treatment as well as survival rates was also presented (Tab. 1, Ref. 33).

Extragastrointestinal stromal tumor mimicking a uterine tumor. A rare clinical entity

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract. These tumors are present in almost all case mutations of KIT-CD117. When located in different places other than the gastrointestinal tract they are called extragastrointestinal stromal tumors (EGISTs). We present the case of a 70-year old patient with abdominal pain. Computed tomography (C/T) and ultrasound (U/S) indicated the existence of a hypoechoic enlarged 9.6 x 10 cm uterus due to leiomyoma. The clinical condition of the patient deteriorated and obtained the characteristics of an acute abdomen. The patient underwent urgent exploratory laparotomy, which revealed the incidental existence of a large tumorous formation in the pouch of Douglas. A total abdominal hysterectomy, bilateral ovarectomy, omentectomy, and tumor resection from the rectouterine pouch were performed. Histology analysis confirmed the diagnosis of a malignant EGIST. EGISTs are infrequent in pelvis. In our case, pelvic EGIST led to an acute pain symptomatology obtaining characteristics of invasive uterine leiomyosarcoma. Pelvic imaging with classical methods of U/S and C/T may lead to confusion and false diagnosis. To the best of our knowledge, this is the first case report about an EGIST located in the rectouterine pouch of Douglas leading to acute abdomen symptomatology.

Thermal balloon endometrial ablation: a systematic review

OBJECTIVE

The aim of our study is to review the role of thermal balloon endometrial ablation (TBEA) as an alternative in treating abnormal uterine bleeding.

METHODS

Articles relevant to our review and relevant references from the initially identified articles on the field that were archived by May 2007, were retrieved from Pubmed.

RESULTS

Success rates ranged from 83 up to 94%, with patient's satisfaction ranging from 57 up to 94%. Persisted menorrhagia could reach 17% in some studies.

CONCLUSION

TBEA is an effective alternative method used in the treatment of menorrhagea which results in a significant reduction in menstrual bleeding and high satisfaction rates. However, a longer follow-up is required to determine the role of such a treatment.

Determination of the necessary total protein substitution requirements in patients with advanced stage ovarian cancer and ascites, undergoing debulking surgery. Correlation with plasma proteins

BACKGROUND

Ascites is common in patients with advanced ovarian carcinoma (AOC). Its drainage during surgery affects plasma proteins. We sought to correlate the volume of ascites with the oncological parameters of the disease, calculate its drainage effect on plasma proteins, and determine the necessary substitution requirements and a clinical way of achieving that.

PATIENTS AND METHODS

We evaluated 138 patients with AOC and ascites who underwent primary cytoreductive surgery. Intraoperatively found ascites and its postoperative production were evaluated. Its drainage effect on plasma proteins and the substitution requirements were determined using a mathematic formula. Human albumin(HA) and fresh frozen plasma (FFP) were used to cover these requirements.

RESULTS

The intraoperative ascites was found to correlate only with the stage of the disease, while its postoperative production correlated with the residual disease. Optimally debulked patients had a mean ascites production of 128 mL on postoperative day 1 compared with 668 mL of the suboptimally debulked. This production required 3 and 5-7 days, respectively, to drop <50 mL. Plasma proteins fell on their minimum level (88.9 versus 80.8%) on the second postoperative day. The protein deficit was calculated to be 379 and 691 g/day, respectively. This deficit was substituted by administering 2 HA and 2 FFP for 3-6 days.

CONCLUSIONS

Ascites drainage affects the postoperative homeostasis of plasma proteins. A mean acute drop of 12-20% is monitored on postoperative day 2. This deficit can be managed with HA and FFP for a minimum of 3 days.

Polymyositis in a patient with recurring ovarian cancer and history of unrelated breast cancer

BACKGROUND

Polymyositis (PM) is an idiopathic inflammatory myopathy. Occasionally, it may present as a paraneoplastic syndrome and it is strongly associated with ovarian and weakly with breast cancer. We present here a case of a 60-year-old patient with sequential breast and ovarian (second primary) carcinomas followed by PM as a paraneoplastic disorder.

CASE REPORT

The patient had been diagnosed with stage I breast carcinoma 3 years ago and had been treated with conservative surgery followed by radiotherapy and six cycles of chemotherapy (CMF). One and a half year later an ovarian carcinoma was diagnosed for which the patient underwent abdominal hysterectomy oophorectomy and omentectomy. The pathological report characterized it as second primary. Adjuvant chemotherapy with carboplatin and taxol was administered. Fourteen months after the initial laparotomy, the patient was re-operated due to ovarian carcinoma recurrence which was involving all lesser pelvis organs. After a successful radical removal of the recurrence the patient developed a fully expressed PM. This case serves to remind that this disease can occur as a paraneoplastic disorder.

Meig's or Pseudomeig's syndrome?

The triad of ascites, hydrothorax in association with a benign ovarian tumor is defined as Meig's syndrome. It is a rare clinical entity. A case of a 62 year-old woman whith dyspnoe, abdominal discomfort and ascites is presented. Clinical and ultrasonographic findings revealed extended palpable pelvic mass originating from the ovaries and ascites as well as hydrothorax of the left lung by chest radiography. The treatment method was surgical intervention. Cytomorphologic studies were positive for malignacy and adenocarcinoma cells were confirmed. The pathogenesis of the pleural and ascites fluids and the importance of CA-125 are discussed (Fig. 2, Ref. 21).

Vaginal carcinoma in a completely prolapsed uterus. A case report

BACKGROUND

The development of genuine vaginal carcinoma onto a completely prolapsed uterus is a very rare condition to deal with.

CASE

We report here the clinical characteristics of a patient with vaginal carcinoma associated with a third-degree prolapsed uterus. The 80-year-old patient was admitted with a completely prolapsed uterus. The cervix was clinically normal but on the nearby prolapsed vaginal wall a large exophytical hard lesion had been developed. Biopsy of the lesion revealed squamous carcinoma.

TREATMENT

The treatment performed was radical vaginal hysterectomy and excision of the upper two-thirds of the vagina without pelvic lymphadenectomy, followed by external beam irradiation. The patient is alive, with no signs of the disease 3.5 years after surgery.

CONCLUSION

Surgical and radiotherapeutic treatments can be effectively combined in patients with vaginal carcinoma and complete genital prolapse, in order to improve survival benefits and reduce morbidity.

Late diagnosis of a neglected cervical carcinoma in an elderly woman: a case report

We report the case of an 88-year-old, Greek patient who was referred to our department with a bleeding mass that occupied her entire vagina. This exophytic tumor had extensive ulcerated areas and originated from the cervix. The biopsies taken from the mass confirmed it to be squamous cell carcinoma. Despite the giant size of the tumor, the parametria and middle and lower vagina were not infiltrated. Rather, the neglected mass created a severe septic condition that was progressing to disseminated intravascular coagulation DIC status. Because of the patient's advanced age and critical condition, we performed a "toilet" operation to remove the tumor mass. We subsequently administered radical radiation therapy with satisfactory results.

The effect of hypertension and anti-hypertensive drugs on endometrial thickness and pathology

OBJECTIVES

We sought to clarify if hypertension has a direct effect on endometrial pathology. Furthermore, we wanted to evaluate the effect of possible differences among the various antihypertensive drugs on the clinico-pathological findings.

PATIENTS AND METHODS

The records of 228 patients who underwent D&C at our tertiary cancer hospital were examined. All other aetiopathogenic factors (DM, tamoxifen, obesity, etc.) for endometrial pathology were excluded, as well as endometrial carcinoma cases. We compared the differences in the clinical symptoms and signs between hypertensive and normotensive women, as well as differences in their histological findings. Furthermore, we carried out a subgroup analysis of the above with respect to the antihypertensive agent(s) the patients used.

RESULTS

One hundred and twenty-three patients (54%) were hypertensive and 105 (46%) were normotensive. Vaginal spotting was present in approximately 75% of patients in both groups, but sonographic endometrial thickening was significantly more prevalent among hypertensive women (52.8% versus 34.3%, p=0.004). Hyperplasia was the commonest positive histological finding among hypertensive women (44.7%), compared with polyps for the normotensives. Furthermore, atypia was censored in 4.1% of hypertensive patients only. The subgroup analysis with respect to the various antihypertensives was similar to the above histological distribution, with the exception of the combination b-blocker plus calcium antagonist, which had a significantly more favourable histological profile with over 60% normal endometria.

CONCLUSIONS

Hypertensive patients tend to require D&C more frequently. Sonographic endometrial thickening is significantly more frequent among them. Hyperplasia with or without atypia occurs in approximately 50% of hypertensive women. No differences in the above were justified depending on the different antihypertensive agents used, with the exception of the b-blocker plus calcium antagonist (+/-ACE inhibitor) combination, which requires further evaluation.