Do obesity and age effect the clinicopathological features and survival outcomes in premenopausal women with endometrial cancer?

PURPOSE

The purpose of this study was to review the effect of age and body mass index (BMI) on the prognosis, demographic characteristics, and pathological features of patients diagnosed with endometrial cancer, specifically before menopause.

MATERIALS AND METHODS

Patients that were diagnosed with endometrial cancer before menopause, were screened retrospectively. Between 1999 and 2011, 163 patients were identified while 40 were excluded. Patients were classified into three groups according to age (under 40 years, between 40-45 years, more than 45 years) and BMI (normal weight group, overweight group, and obese weight group). Demographical characteristics, histopathological features (Stage, grade and histology of the tumor, the presence of myometrial and/or lymphovascular invasion, history of diabetes mellitus, history of hypertension, hormonal contraception method, smoking, parity, infertility, family history, and recurrences) and survival rates were compared among the groups.

RESULTS

In total, 123 patients with a mean of 65.0 months follow up were enrolled into the study. The majority of the patients had endometrioid type in all age-related subgroups. Advanced stage endometrium cancer (Stage 2 and greater) was seen more commonly in the group of patient over 45 years of age against the other age-related subgroups (27.9% vs. 8% vs. 3.3%). Ratio of myometrial invasion more than 50% and occurrence of well-differentiated tumor were seen with a similar ratio among the age-related subgroups. Ratio of nulliparity and infertility were found statistically significant in the group of patients under 45 years of age against the group of patients over 45 years of age (p = 0.001, p = 0.03). The five-year estimated disease-free survival rates of women under 40 years of, women with an age between 40-45 years, and women over the age of 45 years were calculated as 73%, 95%, and 87%, respectively (p = 0.152). Concerning the histopathological features, there were no statistical differences between weight related subgroups. Comorbid conditions (hypertension and diabetes mellitus) were found as statistically high in the obese patients' group (43.5%-25.8%). In contrast to comorbid conditions, nulliparity and infertility histories were observed more often within the normal weight group (55.6%-38.5%). Mean disease-free survival time was calculated as 155.81 months in the normal weight group; 114.691 months in the overweight group, and 144.677 months in the obese group. Five-year disease-free survival rate was calculated as 91%, 81%, and 87%, respectively (p = 0.452).

CONCLUSION

Women with premenopausal cancers generally exhibit early and favorable histopathological symptoms. Although advanced stage endometrium cancer incidence was detected to be higher in the premenopausal endometrium cancer patients aged above 45 years compared to other age subgroups. A significant difference in terms of survival rates between these groups was not reached. In the same manner, the authors did not find a significant difference in survival rates among different weight subgroups of premenopausal endometrium cancer patients. As a secondary result, the authors discovered that diabetes mellitus and hypertension play a key role in patients with a BMI above 30 kg/m2 and nulliparity and infertility play a key role in patients with a BMI below 25 kg/m2 in the development of premenopausal endometrial cancer.

Implications of premature ovarian failure on bone turnover markers and bone mineral density

INTRODUCTION

Premature ovarian failure (POF) is the cessation of ovarian function before the age of 40. The loss of ovarian function, whether premature or not, has an overwhelming impact on female skeletal health, leading to an increased risk of developing osteoporosis because of the lengthened time of exposure to reduced estrogen. The objective of this study was to compare the implications of premature ovarian failure on bone turnover markers and bone mineral density in patients under the age of 40.

MATERIALS AND METHODS

Sixty-one patients with a diagnosis of POF were selected for this prospective study. Patients were divided into two groups according to age, patients < 30 years old (n = 30), and patients > or = 30 years old (n = 31).

RESULTS

Between the two age sub-groups (< 30 and > or = 30 years old), there was a significant difference in menopause rating scale (MRS), lumbar spine t-score, N-telopeptides crosslinks (NTx), and serum bone specific alkaline phosphatase (bALP) between the two age groups (10.93 +/- 7.79 vs 17.38 +/- 8.62; -1.84 +/- 1.47 vs -1.06 +/- 0.93; 58.80 +/- 21.32 vs 41.1 +/- 11.37; 48.99 +/- 42.16 vs 23.76 +/- 10.08, respectively).

CONCLUSION

It is apparent that bone mineral density (BMD) is commonly less in women with POF than normal healthy women. Therefore, measurement of BMD is warranted. At this time, it is not clear how often the tests should be carried out to evaluate BMD. Further prospective studies are required to establish guidelines. However, it seems reasonable to monitor women with POF yearly for the presence of any endocrine dysfunction and to assess BMD at periodic intervals.

A deceiving disease in women for clinicians: peritoneal tuberculosis

INTRODUCTION

Peritoneal tuberculosis (TB) is uncommon in developed countries, although there is an increase in incidence due to the patients with acquired immunodeficiency syndrome and in immigrants from countries with tuberculosis. The aim of the study was to identify characteristic features of peritoneal tuberculosis (TB), which may be useful for the clinical differential diagnosis and management of this deceiving disease.

MATERIALS AND METHODS

For this retrospective study, 18 patients, who were diagnosed with peritoneal TB were identified after surgery.

RESULTS

Initial presentation consisted of ascites, pelvic masses, and elevated levels of CA-125. All patients were initially misdiagnosed as ovarian carcinoma. Tissue biopsies obtained from laparoscopy or laparotomy revealed accurate diagnosis of peritoneal TB.

CONCLUSION

Peritoneal TB should be included in the differential diagnosis ofascites and pelvic masses and can be accurately diagnosed by laparoscopic biopsy.

Pyomyoma after dilatation and curettage for missed abortion

Infection of a leiomyoma is a very rare clinical entity called pyomyoma. Pathology may be encountered during the reproductive period, pregnancy, and even postmenopausal period. In this report, we present a case of pyomyoma which developed after dilatation and curettage managed by broad spectrum antibiotics and myomectomy to preserve the fertility in a 31-year-old patient.

A rare case of lymphangiomyomatosis treated with leuprolide acetate: five-years follow-up

Lymphangiomyomatosis (LAM) is a rare and systemic disease that is characterized by the abnormal proliferation of smooth muscle-like cells in the lungs and along the axial lymphatic system. The authors herein present a rare case of LAM that was treated with long-term use of leuprolide acetate, a gonadotropin-releasing hormone analogue (GnRHa).

Hemoperitoneum and acute abdomen caused by the rupture of ovarian granulosa cell tumor: a case report

Granulosa cell tumors (GCT) constitute 70% of all ovarian sex-cord stromal tumors, which account for less than five percent of all ovarian carcinoma. The authors herein report a rare case of a ruptured GCT of the ovary in a 43-year-old female who was admitted to the emergency department with signs of acute abdomen.

Acute hemorrhage related to spontaneous rupture of an uterine fibroid: a rare case report

The authors present smooth muscle tumors of uncertain malignant potential (STUMP) diagnosis and surgical management of a spontaneously-ruptured degenerated uterine fibroids. A 48-year-old nulliparous presented with a two-day history of abdominal pain, bloating, constipation, and menorrhagia. Within eight hours, her distress level increased. Computed tomography (CT) scanning of the abdomen showed a large, 31 x 25 cm solid-cystic lesion. An emergency laparotomy was indicated. Surgery revealed approximately 2,000 cc of blood and a 30 cm degenerated uterine fibroid with a fundal rupture, cystic, and solid components extending to the lower pole of the liver. Pathology results noted mild nuclear atypia, six mitoses per ten high-power fields (hpf) and necrosis spread that was not coagulative with a STUMP diagnosis. STUMP presents a problematic group of uterine smooth muscle tumors for any clinician. In addition, STUMP can rarely cause acute complications like a rupture. Therefore, prompt diagnosis and effective management are important.

Diffusion-weighted imaging of solid or predominantly solid gynaecological adnexial masses: is it useful in the differential diagnosis?

OBJECTIVES

This study investigated whether diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) values provide specific information that allows the diagnosis of solid or predominantly solid gynaecological adnexial lesions, especially whether they can discriminate benign and malignant lesions.

METHODS

DWI was performed in 37 patients with histologically proven solid or predominantly solid adnexial lesions (22 malignant and 15 benign neoplasms). The lesions in our data set were divided into two groups, all adnexial lesions or lesions of ovarian origin, for evaluation. The areas of the highest signal intensity on DWI (b = 800 s mm(-2)) and the lowest ADC values within the lesions were evaluated.

RESULTS

On DWI, high signal intensity was observed more often in malignant than in benign lesions (p<0.0001). There was no significant difference between the ADC values of the malignant and benign lesions in either the adnexial (0.88±0.16 vs 0.84±0.42; p = 0.96) or the ovarian (0.85±0.14 vs 1.05±0.2; p = 0.133) lesions. When signal intensities on DWI were compared, however, malignant lesions had higher values than the benign lesions in both the adnexial (0.69±0.21 vs 0.29±0.13; p<0.0001) and the ovarian lesions (0.75±0.14 vs 0.37±0.24; p = 0.003).

CONCLUSION

On DWI, high signal intensity was observed more frequently with the malignant lesions.

Factors affecting recurrence and disease-free survival in granulosa cell tumors of the ovary

PURPOSE OF INVESTIGATION

To determine risk factors for prognosis and recurrence in ovarian adult-type granulosa cell tumor (GCT).

METHODS

A retrospective review of GCT cases treated at our university hospital between 1991-2006.

RESULTS

Of 39 patients with GCT, 82% had Stage I disease. The median follow-up period was 71 months. There were 12 cases of recurrence (30.8%) and seven of them had died of disease. The pelvis and liver were the most common sites of recurrence (8 and 3 patients, respectively). Interestingly lymph node recurrence was encountered in two patients. Estimated disease-free survival for five years was 82%. Stage and presence of residual tumor were calculated to be the only associated risk factors for recurrence and prognosis (p < 0.05).

CONCLUSION

Recurrences in GCT might be associated with stage and presence of residual tumor during primary surgery. Although rarely present during diagnosis, lymph node metastasis might be more common in recurrent disease.

Evaluation of serum levels of interleukin-10, interleukin-11 and leukemia inhibitory factor in differentiation of eutopic and tubal ectopic pregnancies

PURPOSE OF STUDY

To investigate whether serum levels of leukemia inhibitory factor (LIF), interleukin 10 (IL-10) and interleukin 11 (IL-11) are different in reference to the site of implantation.

METHODS

Seventeen patients with laparoscopic diagnoses of tubal ectopic pregnancy (EP) and 19 patients with intrauterine pregnancy delivering healthy term neonates (IUP) were prospectively evaluated for LIF, IL-10 and IL-11 levels. The data were compared by using the Student's t-test, chi-square test, Kruskal-Wallis and the Mann-Whitney U test with Bonferroni's correction (p < 0.05) as appropriate.

RESULTS

A statistically significant difference was observed in serum LIF levels between the EP and IUP groups (p = 0.002). Ranges of LIF were 15-300 and 70-1200 ng/ml for the IUP and EP groups, respectively. There were no significant differences between groups in terms of IL-10 and IL-11 levels.

CONCLUSION

LIF, but not IL-10 or IL-11, levels may be increased in early tubal ectopic pregnancies when compared to normal intrauterine pregnancies.

Groin recurrence following stage IA squamous cell carcinoma of the vulva with negative nodes on superficial inguinal lymphadenectomy

PURPOSE OF INVESTIGATION

Stage IA vulvar cancer with a depth of stromal invasion less than 1 mm is generally managed by wide local excision alone since there is less than 1% risk of lymph node involvement.

CASE

A 62-year-old patient was admitted to a university hospital with a suspicious vulvar lesion.

RESULTS

We present the first case of inguinal node and a possible contralateral pubic ramus recurrence following bilateral superficial inguinal lymphadenectomy and wide local resection for Stage 1A vulvar cancer.

CONCLUSION

There is no evidence that extended radical surgery provides a better overall survival or reduces recurrence rate in Stage 1A vulvar carcinomas. Conservative vulvar resection and sentinel node dissection seem to be a rational choice. Nevertheless the disease may recur in the inguinal areas and frequently be lethal, therefore close surveillance and early attempts to treat the recurrent disease before infection and inflammation ensues should be the aim of current treatment strategies.

Cranial imaging spectrum in hypertensive disease of pregnancy

OBJECTIVE

To determine cranial imaging findings in patients with severe preeclampsia, eclampsia and HELLP syndrome and the correlation between these findings and neurological symptoms.

MATERIALS AND METHODS

CT or MRI findings of 120 patients diagnosed with severe preeclampsia, eclampsia and/or HELLP syndrome between January 1998 and December 2005 are presented.

RESULTS

Pathological imaging findings were observed in 28.1% (n = 32) of the severe preeclampsia group, in 43.3% (n = 30) of the HELLP group, in 51.35% (n = 27) of the eclampsia group and in 61.9% (n = 21) of the eclampsia + HELLP group and in 45% of all patients. Thirty-five patients had specific pathology defined as ischemic lesions, edema, and perivascular microhemorrhage. Infarcts were found in seven, intracranial hemorrhage in seven, hydrocephaly in two, dural sinus thrombosis in two and a pineal cyst in one patient. Specific lesions were generally located in the posterior parietal and occipital lobes. Five patients died due to intracranial hemorrhage and one patient due to septic shock.

CONCLUSION

A wide imaging spectrum from the ischemic lesion to severe intracranial hemorrhage can be detected in complicated cases of hypertensive diseases of pregnancy. It is essential to perform cranial imaging in patients with symptoms and neurological deficits.

Conservative treatment of an early ectopic pregnancy in a cesarean scar with systemic methotrexate--case report

PURPOSE OF INVESTIGATION

Pregnancy implanted in a cesarean scar is rare, and is a life-threatening condition due to high risk of uterine rupture, hemorrhage, hysterectomy, and maternal mortality.

CASE REPORT

We describe a 26-year-old woman who presented with five weeks of amenorrhea and a serum hCG level of 10,440 mIU/ml. Transvaginal sonography revealed a gestational sac of 15 x 11 mm containing a yolk sac located in a previous cesarean scar. She was successfully treated conservatively with multi-dose methotrexate. No side-effects were encountered. The serum hCG levels were undetectable in 58 days. The patient had normal menstrual cycles afterwards.

CONCLUSIONS

In the view of increasing cesarean rates, healthcare professionals should be aware of the possibility of a scar pregnancy and the potentially life threatening sequelae. Early diagnosis by transvaginal sonography can improve outcome and minimize the need for emergent surgery. Conservative treatment with systemic methotrexate is an effective option in selected patients.

Invasive squamous carcinoma of the vulva in women aged less than 40 years: report of two cases and a third case diagnosed during pregnancy

PURPOSE OF INVESTIGATION

Invasive squamous cell cancer of the vulva (ISCC) is a rare disease in young patients and in pregnant women. The purpose of this paper was to investigate this type of cancer in women less than 40 years old and to present three cases, one which was diagnosed in the third trimester of pregnancy.

METHODS

Three cases of invasive squamous cell cancer in women under age 40 among the retrospectively analyzed 52 vulvar cancer cases diagnosed between 1995-2002 were investigated.

RESULTS

Women aged 25, 39 and 31, respectively, had Stage 1, 2 and 3 ISCC of the vulva. The first two cases had been spared by surgery and radiotherapy. The third patient was diagnosed during the last trimester of pregnancy. Although she was treated by radical surgery and postoperative radiotherapy, she had a recurrence in the inguinal region at 36 months, and died of disease 12 months later.

CONCLUSION

Vulvar ISCC in young women may occur in association with or without predisposing factors. Although HPV-related type is predominant in the literature, keratinizing type of carcinoma may also be seen in this group of patients. Biopsy from suspected lesions is of paramount importance.

Pelvic actinomycosis mimicking ovarian malignancy: three cases

OBJECTIVE

Three cases of pelvic actinomycosis initially diagnosed as pelvic malignancy and treated surgically are reported.

CASES

The first case was a 38-year-old multiparous woman who was referred to our clinic because of bilateral ovarian solid masses. With the impression of ovarian carcinoma, a laparotomy was performed. During surgery adhesiolysis, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, appendectomy, peritoneal washings, and peritoneal abscess drainage were performed. The second patient was a 37-year-old woman who presented with a left-sided fixed solid mass highly suggestive of pelvic malignancy. Both ureters were found to be dilated with hydronephrosis in the right kidney supporting the diagnosis of retroperitoneal fibrosis. Excision of the mass, colectomy and temporary diverting colostomy and stent insertion to the left ureter were performed. Colostomy repair was performed five months later. On the fifth day postoperatively, fascial necrosis developed so a Bogota-bag was placed on the anterior abdominal wall and left for secondary healing. The third patient was a 51-year-old postmenopausal woman incidentally diagnosed as having a pelvic mass while having been investigated for constipation and nausea. She had had a colostomy one year before and a reanastomosis two months after. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In all cases, histopathologic staining of the specimens revealed chronic inflammation containing actinomycosis abscesses confirmed with microbiologic identification.

CONCLUSION

Pelvic actinomycosis is an uncommon cause of a pelvic mass. However, it should be kept in mind in the differential diagnosis of pelvic masses, especially in the patients with a history of IUD use to avoid an unnecessary extensive surgical procedure.

Laparoscopic evaluation of metastatic ovarian cancer: a case report

OBJECTIVE AND CASE: Both noninvasive and invasive methods have limited value in the diagnosis of metastatic ovarian cancer. We present a case with the initial complaint of abdominal distention in whom primary and metastatic tumor sites were safely diagnosed by using laparoscopy: a gastric tumor with ovarian metastasis.

DISCUSSION

Diagnostic laparoscopy by the open technique provides a safe and effective diagnostic option in patients with metastatic ovarian cancer.

Unscarred uterine rupture after induction of labor with misoprostol: a case report

The rupture of an unscarred uterus is very rare and presents an emergency situation that threatens the life of the fetus and mother. The agents used for induction of labor, like oxytocin and/or prostaglandins, can be responsible for this catastrophic event. We report a case of intrapartum rupture of an intact uterus after using intravaginal misoprostol for cervical ripening and labor induction in a term pregnancy and we discuss the other cases reported in the literature.

The evaluation of misoprostol-related tachysystole in normal and high risk pregnancies

OBJECTIVE

To determine whether misoprostol-related tachysystole is due to the cumulative effect of the drug.

METHODS

A group of preeclamptic patients were chosen and data were compared to non-preeclamptic patients to prove the hypothesis. Among 90 patients evaluated, 45 were preeclamptic while 45 were non-preeclamptic. Six out of 43 preeclamptic patients were diagnosed as having HELLP syndrome. All patients were induced by 50 microg of misoprostol applied to the posterior vaginal fornix with 4-hour intervals for a maximum of three times.

RESULTS

Two patients from both groups were left out of the study leaving 86 patients to evaluate. The number of misoprostol tablets used in the preeclamptic group was significantly higher (2.32 +/- 0.64 preeclamptic vs 1.81 +/- 0.76 tablets non-preeclamptic group; [p = 0.001]) while the number of women giving birth after only one tablet of misoprostol was significantly lower (2/24 preeclamptic vs. 14/32 non-preeclamptic group [p = 0.006, OR 0.116; 95% CI 0.02-0.58]). Although the frequency of tachysytolic patterns observed was different between the two groups, (35% preeclamptic vs 16% non-preeclamptic) this difference was not statistically significant (p = 0.082). It is important to note that an increase of only one case having tachysystole in the preeclamptic group would have converted this difference to significant.

CONCLUSION

Relatively hard induction of labor in preeclamptic patients leads to an increase in the amount of misoprostol used and hence to an increased incidence of tachysystole secondary to the cumulative effect of the drug. These findings seem to support our hypothesis and prove the presence of the cumulative effect of misoprostol.