A Rare Case of Primary Adrenal Epithelioid Angiosarcoma

BACKGROUND Primary adrenal epithelioid angiosarcoma (PAEA) is a very uncommon primary adrenal gland tumor that usually occurs around the age of 60 years and is more common among males. Owing to its rarity and histopathological features, PAEA could be misdiagnosed as adrenal cortical adenoma, adrenal cortical carcinoma, or other metastatic cancers, such as metastatic malignant melanoma and epithelioid hemangioendothelioma. CASE REPORT A 59-year-old male patient presented to our hospital with a complaint of abdominal bloating that started 2 months prior. His vital signs and the results of his physical and neurological examinations were unremarkable. A computed tomography scan showed a lobulated mass arising from the hepatic limb of the right adrenal gland but no evidence of metastasis to the chest or abdomen. The patient underwent right adrenalectomy, and the macroscopic pathological findings from a right adrenalectomy specimen revealed atypical tumor cells with an epithelioid appearance in the background of an adrenal cortical adenoma. Immunohistochemical staining was performed to confirm the diagnosis. The final diagnosis was epithelioid angiosarcoma involving the right adrenal gland with a background adrenal cortical adenoma. The patient had no postoperative complications, pain in the surgical wound, or fever. Therefore, he was discharged with a schedule for followup appointments. CONCLUSIONS PAEA may be misinterpreted as adrenal cortical carcinoma, metastatic carcinoma, or malignant melanoma radiologically and histologically. Immunohistochemical stains are essential for diagnosing PAEA. Surgery and strict monitoring are the main treatments. In addition, early diagnosis is essential for patient recovery.

Prenatal sonographic features of fetal mediastinal teratoma

Mediastinal teratoma can cause severe hydrops fetalis, which worsens the effects of the mass compression on the vital mediastinal organs. A careful sonographic examination is mandatory to demonstrate the characteristic features suggestive of this congenital tumor. We describe these features at 20 weeks gestation. The most prominent finding was the heterogeneous echogenicity of a large cystic-solid mass with hyperechoic dots, seen as a part of the anterior mediastinum immediately posterior to the sternum. Additional diagnostic features included posterior displacement of the heart, low cardiac output, and hypoplasia of the normally structured heart and lungs due to the direct mass compression. These sonographic findings were confirmed at autopsy which confirmed a nonmetastatic immature teratoma. Sonography may enable accurate diagnosis of mediastinal teratoma considering the anterior location and heterogeneous appearance of the mass, posterior displacement of the heart, normal lung morphology, and compression effects on these organs.

Prognostic Value of Tumor Budding in Early-Stage Cervical Adenocarcinomas

Background: Tumor budding has recently been reported as an independent adverse prognostic factor for colorectal adenocarcinomas and other types of carcinoma in the digestive tract. This study aimed to evaluate the prognostic value of tumor budding in patients with early-stage cervical adenocarcinomas and any associations with other clinical and pathological features. Methods: Histological slides of patients with early-stage (IB-IIA) usual-type endocervical adenocarcinoma who underwent radical hysterectomy and pelvic lymph node dissection, without preoperative chemotherapy, between January 2006 and December 2012 were reviewed. Tumor budding was evaluated in routinely-stained sections and defined as detached single cells or clusters of fewer than 5 cells in a tumor invasive front and was stratified based on the number of bud counts in 10-high-power fields as low (<15 buds) and high (≥15 buds). Correlations between tumor bud count and other clinical and pathological variables including follow-up outcomes were assessed. Results: Of 129 patients, a high tumor bud count was observed in 15 (11.6%), positively associated with histologic grade 3 (p<0.001), invasive pattern C (Silva System) (p=0.004), lymph node metastasis (p=0.008), stage IB2-IIA (p=0.016), and tumor size >2 cm (p=0.036). Kaplan-Meyer analysis showed a significant decrease in both disease-free survival and cancer-specific survival for patients with a high tumor bud count (p=0.027 and 0.031, respectively). On multivariate analysis, histologic grade 3 was the only independent predictor for decreased disease-free survival (p=0.004) and cancer-specific survival (p=0.003). Conclusions: A high tumor budding count based on assessment of routinely-stained sections was found to be associated with decreased disease-free and cancer-specific survival in patients with early-stage cervical adenocarcinomas. However, it was not found to be an independent prognostic predictor in this study.

A Simple Rule for Prenatal Diagnosis of Total Anomalous Pulmonary Venous Return

The objective of this series was to describe a simple rule for prenatal diagnosis of total anomalous pulmonary venous return (TAPVR). Fourteen fetuses had a prenatal diagnosis of TAPVR by the simple rule, including the following components: (1) the major criterion, which was the absence of a connection between the pulmonary vein and the left atrium; and (2) at least 1 of the following minor criteria: (a) the presence of a vascular confluence behind the atria, (b) abnormal spectral Doppler waveforms in the pulmonary veins, (c) a smooth posterior wall of the left atrium, (d) increased retroatrial space, (e) a dilated coronary sinus (cardiac type), (f) a dilated superior vena cava or brachiocephalic vein, and (g) an additional vessel on the 3-vessel/3-vessel and trachea view or a vertical descending vein. All were accurately diagnosed, and none were missed by the diagnosis. In summary, the simple rule described is helpful in increasing the number of accurate prenatal diagnoses of TAPVR.

Genotyping for Human Papillomavirus (HPV) 16/18/52/58 Has a Higher Performance than HPV16/18 Genotyping in Triaging Women with Positive High-risk HPV Test in Northern Thailand

Background

Testing for high-risk human papillomavirus DNA (HPV test) has gained increasing acceptance as an alternative method to cytology in cervical cancer screening. Compared to cytology, HPV test has a higher sensitivity for the detection of histologic high-grade squamous intraepithelial lesion or worse (HSIL+), but this could lead to a large colposcopy burden. Genotyping for HPV16/18 has been recommended in triaging HPV-positive women. This study was aimed to evaluate the screening performance of HPV testing and the role of genotyping triage in Northern Thailand.

Methods

A population-based cervical screening program was performed in Chiang Mai (Northern Thailand) using cytology (conventional Pap test) and HPV test (Hybrid Capture 2). Women who had abnormal cytology or were HPV-positive were referred for colposcopy. Cervical samples from these women were genotyped using the Linear Array assay.

Results

Of 5,456 women, 2.0% had abnormal Pap test results and 6.5% tested positive with Hybrid Capture 2. Of 5,433 women eligible for analysis, 355 with any positive test had histologic confirmation and 57 of these had histologic HSIL+. The sensitivity for histologic HSIL+ detection was 64.9% for Pap test and 100% for Hybrid Capture 2, but the ratio of colposcopy per detection of each HSIL+ was more than two-fold higher with Hybrid Capture 2 than Pap test (5.9 versus 2.8). Genotyping results were available in 316 samples. HPV52, HPV16, and HPV58 were the three most common genotypes among women with histologic HSIL+. Performance of genotyping triage using HPV16/18/52/58 was superior to that of HPV16/18, with a higher sensitivity (85.7% versus 28.6%) and negative predictive value (94.2% versus 83.9%).

Conclusions

In Northern Thailand, HPV testing with genotyping triage shows better screening performance than cervical cytology alone. In this region, the addition of genotyping for HPV52/58 to HPV16/18 is deemed necessary in triaging women with positive HPV test.

Cytological Anal Squamous Intraepithelial Lesions Associated with Anal High-Risk Human Papillomavirus Infections among Men Who Have Sex with Men in Northern Thailand

BACKGROUND

Anal cancer, one of human papillomavirus (HPV) related malignancies, has increased in recent decades, particularly among men who have sex with men (MSM) and HIV-infected (HIV+) persons. We aimed to explore the prevalence of anal squamous intraepithelial lesions (ASIL) using Papanicolau (Pap) screening among MSM in northern Thailand and its associated factors.

METHODS

Two hundreds MSM aged ≥18 years reporting receptive anal intercourse in the prior 6 months were recruited from July 2012 through January 2013. Medical history and behavioral data were collected by staff interview and computer-assisted self interview. Anal Pap smear, HPV genotyping, and HIV testing were performed. Two pathologists blinded to HPV and HIV status reported cytologic results by Bethesda classification.

RESULTS

Mean age was 27.2 years (range 18-54). Overall, 86 (43.0%) had ASIL: 28 (14.2%) with atypical cells of undetermined significance (ASCUS), 1 (0.5%) with atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H), 56 (28.4%) with low-grade squamous intraepithelial lesion (LSIL), and 1 (0.5%) with high-grade squamous intraepithelial lesion (HSIL). ASIL was associated by univariate analysis (p ≤0.05) with older age, gender identity other than bisexual (i.e., gay men and transgender women), rectal douching, anal symptoms, genital warts, HIV positivity, and high-risk-HPV infection. However, on multiple logistic regression ASIL was associated only with high-risk HPV type (p = 0.002) and HIV infection (p = 0.01).

CONCLUSIONS

ASIL is quite common in high-risk MSM in northern Thailand and is associated with high-risk HPV types and HIV infection. Routine anal Pap screening should be considered, given the high frequency of ASIL, particularly in the HIV+. High resolution anoscopy (HRA), not done here, should be to confirm PAP smears whose sensitivity and specificity are quite variable. Timely HPV vaccination should be considered for this population.

Hemodynamic studies of isolated absent ductus venosus

OBJECTIVE

The objective of this article is to evaluate hemodynamic changes among fetuses with isolated absent ductus venosus (IADV) diagnosed by prenatal ultrasonography.

PATIENTS AND METHODS

Fetuses with prenatal diagnosis of IADV were recruited and followed. Hemodynamic assessment was performed in all cases, including measurement of cardiac dimensions, shortening fraction, myocardial performance index, preload index in the inferior vena cava and the presence of venous pulsations in the umbilical vein (UV).

RESULTS

Nine fetuses of IADV were assessed, including six cases with extra-hepatic UV drainage and three with intra-hepatic drainage. All fetuses with extra-hepatic UV drainage showed an elevated preload index in the inferior vena cava, venous pulsations in the UV and cardiomegaly. Of them, four had hydrops, two showed poor cardiac function and three resulted in perinatal mortality. Three cases with intra-hepatic drainage had continuous flow in the UV, normal in all hemodynamic parameters and all survived.

CONCLUSION

Hemodynamic assessment of fetuses with IADV was helpful in predicting the development of hydrops and perinatal mortality. The poor prognostic factors included cardiac overload, cardiomegaly, poor myocardial performance, increased preload, the presence of venous pulsations and extra-hepatic UV drainage. © 2015 John Wiley & Sons, Ltd.

Prenatal differentiation between truncus arteriosus (Types II and III) and pulmonary atresia with ventricular septal defect

OBJECTIVE

To describe antenatal sonographic signs that help in the differentiation of truncus arteriosus Types II and III (TA-II/III) from pulmonary atresia with ventricular septal defect (PA-VSD).

METHODS

From a database of fetal echocardiographic examinations, we identified fetuses with sonographic features of a single great artery with VSD and relatively normal four-chamber view. Records were reviewed, comparing fetuses with TA-II/III and those with PA-VSD, with particular focus on: 1) characteristics of the overriding vessel, 2) appearance of the semilunar valves, 3) competence of the semilunar valves, 4) presence of major aortopulmonary collateral arteries (MAPCA), 5) main pulmonary artery being without antegrade flow, 6) site of arterial branching from the great artery and 7) other minor features, such as cardiac axis or associated anomalies.

RESULTS

Seventeen fetuses were identified, eight with TA-II/III and nine with PA-VSD. Among the eight fetuses with TA-II/III, seven had abnormal valves and six had valve regurgitation, compared with none of the nine PA-VSD fetuses. Five TA-II/III fetuses had early branching to supply the lungs, whereas most fetuses with PA-VSD had more distal branching. Notably, in six of the TA-II/III fetuses, the root of the single great artery originated predominantly from the right ventricle, while all but one of the PA-VSD fetuses had typical equal overriding of the VSD. The main pulmonary artery was without antegrade flow in two cases with PA-VSD. Finally, four cases with PA-VSD had MAPCA, in two of which this was identified prenatally.

CONCLUSION

Identification of abnormal arterial valves or valve regurgitation, site of origin of branching, presence of overriding of the great artery, a main pulmonary artery without antegrade flow and MAPCA are helpful in differentiating between TA-II/III and PA-VSD.

Performance of HPV DNA testing with hybrid capture 2 in triaging women with minor cervical cytologic abnormalities (ASC-US/LSIL) in Northern Thailand

BACKGROUND

Minor cervical cytologic abnormalities include atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL). Approximately 10-20% of women with minor cytologic abnormalities have histologic high-grade squamous intraepithelial or worse lesions (HSIL+). In Thailand, women with minor cytologic abnormalities have a relatively high risk of cervical cancer, and referral for colposcopy has been suggested. A triage test is useful in the selection of women at risk for histologic HSIL+ to reduce the colposcopy burden. The aim of this study was to assess the performance of high-risk HPV DNA test in triage of women with minor cytologic abnormalities in northern Thailand.

MATERIALS AND METHODS

All women with ASC-US/LSIL cytology who were referred to our colposcopy clinic from October 2010 to February 2014 were included. HPV DNA testing was performed using Hybrid Capture 2 (HC2). All patients received colposcopic examination. Accuracy values of HC2 in predicting the presence of histologic HSIL+ were calculated.

RESULTS

There were 238 women in this study (121 ASC-US and 117 LSIL). The HC2 positivity rate was significantly higher in the LSIL group than in ASC-US group (74.8% versus 41.0%, p<0.001). Histologic HSIL+ was detected in 9 women (7.4%) in the ASC-US group and 16 women (13.7%) in the LSIL group (p=0.141). There was no histologic HSIL+ detected among HC2-negative cases (sensitivity and negative predictive value of 100%). The performance of HC2 triage was highest among women aged >50 years with ASC-US cytology. An increase in the cut-off threshold for positive HC2 resulted in a substantial decrease of sensitivity and negative predictive value.

CONCLUSIONS

HPV DNA testing with HC2 shows very high sensitivity and negative predictive value in triage of women with minor cervical cytologic abnormalities in northern Thailand. An increase of the cut-off threshold for HC2 triage is not recommended in this region.

High performance of combined HPV testing and genotyping for HPV16/18/52/58 in triaging women with minor cervical cytological abnormalities in northern Thailand

Human papillomavirus (HPV) infection is an important cause of cervical cancer. Screening with cytology or combined cytology and HPV testing helps to detect early cervical cancers and precancerous lesions (high-grade squamous intraepithelial lesion or worse [HSIL+]). Minor cytological abnormalities (atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion) account for the majority of abnormal cervical cytology results, but only 10-20% of women with minor cytological abnormalities have histologic HSIL+. Triage tests are useful to identify the high-risk patients and reduce the colposcopy burden. This study was aimed to evaluate the triage performance of combined HPV DNA testing and genotyping. Cervical samples from women with minor cytological abnormalities, who underwent colposcopy at Chiang Mai University Hospital in northern Thailand between October 2010 and February 2014, were tested for HPV DNA using Hybrid Capture 2 (HC2). Genotyping was performed using Linear Array assay. Of 223 women with cervical histology confirmation, histologic HSIL+ was detected in 25 women (11.2%). The sensitivity, specificity, positive predictive value, and negative predictive value of 3 triage methods for histologic HSIL+ were; 100%, 47.5%, 19.4%, and 100% by HC2 only; 40.0%, 88.4%, 30.3%, and 92.1% by combined HC2 and genotypes HPV16/18; and 96.0%, 75.8%, 33.3%, and 99.3% by combined HC2 and genotypes HPV16/18/52/58. Triage using combined HC2 and genotypes HPV16/18/52/58 showed significantly greater area under the receiver operating curve than the other 2 methods (P < 0.001). Combined HPV DNA testing and genotyping for HPV16/18/52/58 is useful for triaging women with minor cervical cytological abnormalities in northern Thailand.

Population-based cervical cancer screening using high-risk HPV DNA test and liquid-based cytology in northern Thailand

BACKGROUND

Northern Thailand is a region with a high cervical cancer incidence. Combined high-risk HPV (hrHPV) DNA testing and cytology (co-testing) has increasingly gained acceptance for cervical cancer screening. However, to our knowledge, data from a population-based screening using co-testing have not been available in this region. This study therefore aimed to evaluate the performance of cytology and hrHPV test in women in northern Thailand.

MATERIALS AND METHODS

Cervical samples were collected for hybrid capture 2 (HC2) testing and liquid-based cytology from women aged 30 to 60 years who were residents in 3 prefectures of Chiang Mai in northern Thailand between May and September 2011. Women with positive cytology were referred to colposcopy, while women with positive for HC2 only were followed for 2 years.

RESULTS

Of 2,752 women included in this study, 3.0% were positive in both tests, 4.1% for HC2 only, and 1.3% had positive cytology only. At baseline screening, positive HC2 was observed in 70.6% among cytology-positive women compared with 4.3% among cytology-negative women. The prevalence of positive HC2 or cytology peaked in the age group 35-39 years and was lowest in the age group 55-60 years. High-grade squamous intraepithelial lesion or worse lesions (HSIL+) were histologically detected in 23.5% of women with positive baseline cytology and in 9.8% of women with positive baseline HC2 only on follow-up. All women with histologic HSIL+ had positive baseline HC2.

CONCLUSIONS

The hrHPV test is superior to cytology in the early detection of high-grade cervical epithelial lesions. In this study, the prevalence of histologic HSIL+ on follow-up of women with positive hrHPV test was rather high, and these women should be kept under careful surveillance. In northern Thailand, hrHPV testing has a potential to be used as a primary screening test for cervical cancer with cytology applied as a triage test.

Prognostic model in patients with early-stage squamous cell carcinoma of the uterine cervix: a combination of invasive margin pathological characteristics and lymphovascular space invasion

BACKGROUND

This study aimed to develop a prognostic model in patients with early-stage cervical squamous cell carcinoma based on clinicopathological features, including invasive margin characteristics.

MATERIALS AND METHODS

Clinicopathological features and outcomes of 190 patients with FIGO stage IB-IIA cervical squamous cell carcinoma treated by surgery were collected and analyzed for factors associated with tumor recurrence. In addition to well-recognized pathological risk factors, the pathological characteristics of invasive margin (type of invasive pattern and degree of stromal desmoplasia and peritumoral inflammatory reaction) were also included in the analysis. Multiple scoring models were made by matching different clinicopathological variables and/ or different weighting of the score for each variable. The model with the best performance in the prediction of recurrence and decreased survival was selected.

RESULTS

The model with the best performance was composed of a combined score of invasive pattern, lymphovascular space invasion (LVSI), and degree of inflammatory reaction and stromal desmoplasia (total score =10). Compared to those with score ≤ 8, the patients with score 9-10 had a significantly higher recurrence rate in the overall group (p<0.001) and the subgroup without adjuvant therapy (p<0.001), while the significance was marginal in the subgroup with adjuvant therapy (p=0.069). In addition, the patients with score 9-10 had a higher rate of tumor recurrence at distant sites (p=0.007). The disease-free survival was significantly lower in the patients with score 9-10 than those with score ≤ 8 among the overall patients (p<0.001), in the subgroup without adjuvant therapy (p<0.001), and the subgroup with adjuvant therapy (p=0.047).

CONCLUSIONS

In this study, a prognostic model based on a combination of pathological characteristics of invasive margin and LVSI proved to be predictive of tumor recurrence and decreased disease-free survival in patients with early-stage cervical squamous cell carcinoma.

Prognostic value of pathological characteristics of invasive margins in early-stage squamous cell carcinomas of the uterine cervix

BACKGROUND

To evaluate the pathological characteristics of invasive margins in early-stage cervical squamous cell carcinomas and their association with other clinicopathological features including clinical outcomes.

MATERIALS AND METHODS

Patients with FIGO stage IB-IIA cervical squamous cell carcinomas who received surgical treatment and had available follow-up information were identified. Their histological slides were reviewed for prognostic variables including tumor size, grade, extent of invasion, lymphovascular invasion, involvement of vaginal margin or parametrium, and lymph node metastasis. The characteristics of invasive margins including invasive pattern (closed, finger-like, or spray-like type), degree of stromal desmoplasia, and degree of peritumoral inflammatory reaction were evaluated along the entire invasive fronts of tumours. Associations between the characteristics of invasive margins and other clinicopathological variables and disease-free survival were assessed.

RESULTS

A total of 190 patients were included in the study with a median follow-up duration of 73 months. Tumour recurrence was observed in 18 patients (9%). Spray-like invasive pattern was significantly more associated as compared with closed or finger-like invasive pattern (p=0.005), whereas the degree of stromal desmoplasia or peritumoral inflammatory reaction was not. Low degree of peritumoral inflammatory reaction appeared linked with lymph node metastasis (p=0.021). In multivariate analysis, a spray-like invasive pattern was independently associated with marked stromal desmoplasia (p=0.013), whilst marked desmoplasia was also independently associated with low inflammatory reactions (p=0.009). Furthermore, low inflammatory reactions were independently associated with positive margins (p=0.022) and lymphovascular invasion (p=0.034). The patients with spray-like invasive pattern had a significantly lower disease-free survival compared with those with closed or finger-like pattern (p=0.004).

CONCLUSIONS

There is a complex interaction between cancer tissue at the invasive margin and changes in surrounding stroma. A spray-like invasive pattern has a prognostic value in patients with early-stage cervical squamous cell carcinoma.

Cervical pregnancy with massive bleeding after treatment with methotrexate

This report describes a catastrophic bleeding following methotrexate treatment of cervical pregnancy and dramatic response to Bakri surgical obstetric silicone (SOS) balloon tamponade in controlling massive bleeding. A 42-year-old woman was diagnosed for cervical pregnancy with a viable fetus at 12 weeks by transvaginal ultrasound. Conservative treatment with intrafetal potassium chloride injection and systemic methotrexate were instituted. On the sixth day of therapy, catastrophic bleeding lead to hypovolemic shock. After resuscitation and blood transfusion, we attempt to control the bleeding with evacuation and curettage but was unsuccessful. Bakri SOS balloon tamponade was applied with immediate and effective response. Nevertheless, total abdominal hysterectomy was performed. In conclusion, conservative treatment of cervical pregnancy with systemic methotrexate could be catastrophic in some patients. Control of active bleeding with Bakri SOS balloon tamponade may possibly be helpful in case of uncontrolled bleeding in selected cases.

Chronic histiocytic intervillositis with cytomegalovirus placentitis in a case of hydrops fetalis

Chronic histiocytic intervillositis (CHI) is an infrequent inflammatory placental disorder associated with unfavorable pregnancy outcomes and a high rate of recurrence. This disorder is thought to reflect a maternal delayed hypersensitivity response to fetal antigen(s) in placental tissue. We report a case of a 20-week-gestation hydropic fetus in which the placenta showed chronic histiocytic intervillositis with cytomegalovirus placentitis. Immunophenotyping studies supported a delayed hypersensitivity response. This is the first report of these two diseases co-occurring, raising the possibility of a relationship between chronic histiocytic intervillositis and infection. Chronic histiocytic intervillositis may represent an idiosyncratic immune response, in this case to cytomegalovirus.

Intra-leiomyoma massive hemorrhage after delivery

Massive bleeding into a uterine leiomyoma is an extremely rare cause of hypovolemic shock. Only one case of this life-threatening condition has been reported. Our patient was a 39-year-old woman who had a gradual growth of a subserous myoma throughout pregnancy and sudden rapid growth after cesarean section at 35 weeks of gestation. The rapid growth was due to intra-tumor massive bleeding and was associated with hypovolemic shock without evidence of external or intra-abdominal hemorrhage. We hypothesize that a rapid decrease in size of the uterus after delivery might have compressed the venous drainages, which were more vulnerable to occlusion than arterial blood flows, resulting in blood sequestration into the tumor leading to hypovolemia.

Leiomyosarcoma with osteoclast-like giant cells of the uterus: a case report and literature review

The presence of osteoclast-like giant cells (OGC) has been reported as a rare and distinct feature in uterine leiomyosarcoma. To present knowledge, 11 cases have been described in the English literature. The authors report an additional example in a 35-year-old woman who presented with a pelvic mass. Pulmonary metastasis was detected by the preoperative CT scan. The hysterectomy specimen revealed a 11.5 cm intramural mass with hemorrhagic and necrotic center The histologic examination revealed pleomorphic sarcoma with OGC. The neoplastic cells were immunoreative for smooth muscle actin and desmin. Minor intermixing component of conventional leiomyosarcoma and leiomyoma were identified at the periphery of the malignant component. The patient died of disease after 16 months of diagnosis. To our knowledge, this is the youngest case of uterine leiomyosarcoma with OGC. Leiomyosarcoma with OGC has an aggressive clinical course. The tumor may occur in young patient and may arise from pre-existing leiomyoma.

Cyclooxygenase-2 expression in cervical squamous cell carcinoma: the significance of expression in neoplastic cells within the lymphovascular space

BACKGROUND

Cyclooxygenase-2 (COX-2) activity is related to the development and progression of cervical cancer. Previous studies have shown that COX-2 expression in early stage (stage IB-IIA) cervical squamous cell carcinoma is associated with lymph node metastasis in tumors with lymphovascular space invasion (LVSI), and that COX-2 expression may facilitate lymph node metastasis after LVSI occurs. In this study, we evaluated whether COX-2 expression of neoplastic cells within lymphovascular spaces (tumor emboli) would provide additional prognostic information.

METHODS

Immunohistochemical stained slides for COX-2 on 150 cases of stage IB-IIA cervical squamous cell carcinoma with LVSI were evaluated for expression of COX-2 in tumor emboli. Results were correlated with overall COX-2 expression of tumor and clinicopathologic features using statistical analysis.

RESULTS

Expression of COX-2 was detected in 49.3% of cases. Expression of COX-2 in tumor emboli (LV-COX-2 expression) was identified in 61 cases (40.7%). LV-COX-2 expression was associated with high LVSI count (p<0.001) and had a marginal association with tumor COX-2 expression (p= 0.050) and lymph node metastasis (p= 0.063). In tumors showing high LVSI count, LV-COX-2 expression was an independent predictor for lymph node metastasis (p= 0.038, 95% CI= 1.030-2.725) whereas tumor COX-2 expression (p= 0.550) was not.

CONCLUSION

Evaluation of COX-2 expression in tumor emboli may provide additional prognostic value for lymph node metastasis in cervical squamous cell carcinomas with a high LVSI count.

E-flow doppler indices for prediction of benign and malignant ovarian tumors

OBJECTIVE

To determine the validity of pulsatility and resistance index of transabdominal Doppler ultrasound (e-flow) in distinguishing between benign and malignant adnexal masses.

METHODS

A cross-sectional descriptive study was conducted on patients scheduled for elective surgery due to adnexal masses at Maharaj Nakorn Chiang Mai Hospital, Thailand, between April 2006 and March 2008. All patients were sonographically evaluated for pulsatility and resistance indices aided with color e-flow within 24 hours of surgery. The examinations were performed by the same experienced sonographer, who had no information on the patients, to differentiate between benign and malignant adnexal masses based on Doppler indices. The final diagnoses were based on either pathological or operative findings, used as gold standards.

RESULTS

Three hundred and twenty-nine patients were recruited and 23 were excluded, since the masses were finally not proven to be adnexal, for example with intrauterine myomas. Of the remaining 306 cases available for analysis, 191 were benign and 115 were malignant. The sensitivity and specificity of the pulsatility index for distinction were 93.0% and 92.7%, respectively and the values for the resistance index were 94.8 % and 93.2%.

CONCLUSIONS

Pulsatility and resistance indices with transabdominal Doppler ultrasound (e-flow) have high accuracy for differentiating between benign and malignant adnexal masses.

Fetal cytomegalovirus infection associated with cerebral hemorrhage, hydrops fetalis, and echogenic bowel: case report

We describe some fetal ultrasound findings associated with intrauterine cytomegalovirus (CMV) infection. We report a 38-year-old gravida 3, para 2 at 16 weeks of gestation who underwent ultrasound examination for anomaly screening. The scan revealed an extensive irregular echogenic area in the fetal brain, especially at the level of lateral ventricles, suggestive of intraventricular and cerebral hemorrhage. Cardiomegaly, hepatomegaly, and mild ascites as well as an echogenic bowel were demonstrated. Abnormal chromosomes and hemoglobin Bart disease were excluded by analysis of fetal blood. Follow-up ultrasound at 20 weeks of gestation showed frank hydrops fetalis, and termination of the pregnancy was performed based on the couple's decision, giving stillbirth to a male fetus weighing 450 g. Autopsy findings showed intracerebral hemorrhage (right cerebral hemisphere) and hydrops fetalis with hepatosplenomegaly. Microscopic investigation showed typical changes of CMV infection in several organs, including brain, thyroid gland, lung, liver, kidney, heart, pancreas, and placenta. Sonographically, the combination of hydrops fetalis, cerebral hemorrhage, and hyperechoic bowel should raise the possibility of a CMV infection, particularly in cases with no obvious cause of hydrops fetalis.

Epstein-Barr virus–associated smooth muscle tumor presenting as a vulvar mass in an acquired immunodeficiency syndrome patient: a case report

Smooth muscle tumors in immunocompromised patients have a strong association with Epstein-Barr virus (EBV) infection. EBV-associated smooth muscle tumors (EBV-SMT) are considered as a distinct group of smooth muscle tumors with different clinicopathologic features from conventional smooth muscle tumors. A 31-year-old female patient presented with a 2-cm mass at the left labium majus, the clinical diagnosis of which was a Bartholin lesion. She had acquired immunodeficiency syndrome diagnosed 29 months before. Excisional biopsy revealed a cellular tumor composed of round- to spindle-shaped cells with mild to moderate nuclear atypia. The tumor cells were immunoreactive for smooth muscle actin and muscle actin (HHF-35). Evidence of EBV infection was confirmed by in situ hybridization for EBV-encoded small RNA-1. To our knowledge, this is the first case of EBV-SMT presenting as a vulvar mass. EBV-SMT should be included in the differential diagnoses of mesenchymal tumor in patients with immunosuppression and in the differential diagnoses of smooth muscle tumor in uncommon sites, including the vulva.

Sonographic features of female pelvic tuberculous peritonitis

OBJECTIVE

The purpose of this study was to evaluate the sonographic features of tuberculous peritonitis in an attempt to facilitate the recognition of this disorder preoperatively.

METHODS

The sonographic findings of 16 patients who had tuberculous peritonitis were reviewed.

RESULTS

The sonographic findings showed that 14 of the 16 patients had ascites; 10 of these had fine, complete and incomplete mobile septations. Of these 10 patients, 4 had ascites with a latticelike appearance, and 2 had ascites with a parallel violin string appearance, which to our knowledge has not been described previously; 3 had particulate ascites. Peritoneal and omental thickening or nodules were identified in 9 patients. Two patients showed bilateral complex adnexal masses with multiloculated fluid with a thick wall-like tubo-ovarian abscess.

CONCLUSIONS

Tuberculous peritonitis seems to have characteristic sonographic features, especially the findings of peritoneal and omental thickening and ascites with fine, mobile septations. These sonographic findings may provide valuable information to help with further investigations and may prevent unnecessary laparotomies.

Subjective sonographic assessment for differentiation between malignant and benign adnexal masses

OBJECTIVE

To determine the accuracy of subjective sonographic assessment in distinguishing between benign and malignant adnexal masses.

STUDY DESIGN

Cross-sectional descriptive study.

METHODS

The patients scheduled for elective surgery due to adnexal masses were recruited into the study. All patients were sonographically examined within 72 hours of surgery were subjectively evaluated by the experienced sonographer, who had no any information of the patients, to differentiate between benign and malignant adnexal masses based on sonographic morphology. The final diagnoses, used as gold standard, were based on either pathological or operative findings.

RESULTS

One hundred and fifty-eight patients with 174 adnexal masses, (benign; 108 and malignant; 66) were recruited into the study. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were of 89.7%, 84.9 % and 92.6 %, 87.5% and 90.9%, respectively.

CONCLUSIONS

Subjective evaluation of sonographic morphology has high accuracy in differentiating between benign and malignant adnexal masses.

Numerous intracystic floating balls as a sonographic feature of benign cystic teratoma: report of 5 cases

OBJECTIVE

The purpose of this series was to describe the unusual but unique sonographic pattern of mature cystic teratoma.

METHODS

Five patients of reproductive age with clinical manifestations of a pelvic mass were evaluated with sonography for treatment planning.

RESULTS

All 5 cases showed the similar sonographic pattern of a large cystic tumor filled with multiple echogenic spherical structures floating in the cystic background. Of the 5 patients, 3 had rather large balls varying in size between 1 and 4 cm in the same tumor masses, whereas the other 2 had numerous smaller balls of about 0.5 cm in diameter. The numerous crowded very small echogenic balls in the last 2 cases mimicked solid nodules representing malignancy. However, there was no vascularization in the balls, which suggested a benign nature. The postoperative pathologic diagnosis was mature cystic teratoma without any malignant component in all cases.

CONCLUSIONS

The sonographic feature of intracystic floating echogenic balls is probably pathognomonic for mature teratoma and is easily detected in most cases. Color Doppler sonography is helpful in differentiating these benign nodules (small balls) from malignant tumors.