Do Exophytic and Endophytic Patterns in Borderline Ovarian Tumors Have Different Prognostic Implications? A Large Multicentric Experience

Borderline ovarian tumor (BOT) accounts for 15-20% of all epithelial ovarian tumors. Concerns have arisen about the clinical and prognostic implications of BOT with exophytic growth patterns. We retrospectively reviewed all cases of BOT patients surgically treated from 2015 to 2020. Patients were divided into an endophytic pattern (with intracystic tumor growth and intact ovarian capsule) and an exophytic pattern (with tumor growth outside the ovarian capsule) group. Among the 254 patients recruited, 229 met the inclusion criteria, and of these, 169 (73.8%) belonged to the endophytic group. The endophytic group showed more commonly an early FIGO stage than the exophytic group (100.0% vs. 66.7%, p < 0.001). Furthermore, tumor cells in peritoneal washing (20.0% vs. 0.6%, p < 0.001), elevated Ca125 levels (51.7% vs. 31.4%, p = 0.003), peritoneal implants (0 vs. 18.3%, p < 0.001), and invasive peritoneal implants (0 vs. 5%, p = 0.003) were more frequently observed in the exophytic group. The survival analysis showed 15 (6.6%) total recurrences, 9 (5.3%) in the endophytic and 6 (10.0%) patients in the exophytic group (p = 0.213). At multivariable analysis, age (p = 0.001), FIGO stage (p = 0.002), fertility-sparing surgery (p = 0.001), invasive implants (p = 0.042), and tumor spillage (p = 0.031) appeared significantly associated with recurrence. Endophytic and exophytic patterns in borderline ovarian tumors show superimposable recurrence rates and disease-free survival.

Knowledge and attitudes towards clinical trials among women with ovarian cancer: results of the ACTO study

Background

Despite several initiatives by research groups, regulatory authorities, and scientific associations to engage citizens/patients in clinical research, there are still obstacles to participation. Among the main discouraging aspects are incomplete understanding of the concepts related to a clinical trial, and the scant, sometimes confused, explanations given. This observational, cross-sectional multicenter study investigated knowledge, attitudes and trust in clinical research.

We conducted a survey among women with ovarian cancer at their first follow-up visit or first therapy session, treated in centers belonging to the Mario Negri Gynecologic Oncology (MaNGO) and Multicenter Italian Trials in Ovarian Cancer (MITO) groups. A questionnaire on knowledge, attitudes and experience was assembled ad hoc after a literature review and a validation process involving patients of the Alliance against Ovarian Cancer (ACTO).

Results

From 25 centers 348 questionnaire were collected; 73.5% of responders were 56 years or older, 54.8% had a high level of education, more than 80% had no experience of trial participation. Among participants 59% knew what clinical trials were and 71% what informed consent was. However, more than half did not know the meaning of the term randomization. More than half (56%) were in favor of participating in a clinical trial, but 35% were not certain. Almost all responders acknowledged the doctor’s importance in decision-making. Patients’ associations were recognized as having a powerful role in the design and planning of clinical trials.

Conclusions

This study helps depict the knowledge and attitudes of women with ovarian cancer in relation to clinical trials, suggesting measures aimed at improving trial “culture”, literacy and compliance, and fresh ways of communication between doctors and patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-00970-w.

Obstetrics outcomes after complete and partial molar pregnancy: Review of the literature and meta-analysis

The hydatidiform mole is a rare gynecological disease rising from the trophoblastic. Post-molar pregnancies have an extremely variable course, varying from repeated abortions, stillbirths, preterm births, live births, or recurring in further molar pregnancies. Literature on obstetric outcomes following molar pregnancy is poor, often including monocentric studies, and with data collected from national databases. This review and meta-analysis aim to analyze the obstetric outcomes after conservative management of complete (CHM) and partial (PHM) molar pregnancies. The meta-analysis was performed following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). Six studies met the inclusion. Of the total 25,222 patients, 13,129 complete (52.1 %) and 12,093 partial (47.9 %) molar pregnancies were included. Live births rate after CHM was statistically higher (p = 0.002) compared to the live births after PHM (53.6 % vs. 51.0 %, 3266 vs. 1807 cases, respectively). Studies showed heterogeneity I² = 57.7 %, pooled proportion = 0.2 %, and 95 % Confidence Interval (CI) 0.6 to 0.9. No statistically significant difference was demonstrated for ectopic pregnancies (p = 0.633), miscarriage (p = 0.637), preterm birth (p = 0.865), stillbirth (p = 0.911), termination of pregnancy (p = 0.572), and complete molar recurrence (p = 0.580) after CHM and PHM. Partial molar recurrence occurred more frequently after PHM than CHM (0.4 % vs. 0.3 %, 52 vs. 37 cases, respectively, p = 0.002). Careful counseling on the obstetric subsequent pregnancies outcomes should be provided to patients eager for further pregnancy and further studies are needed to confirm these results.

Long term complications following pelvic and para-aortic lymphadenectomy for endometrial cancer, incidence and potential risk factors: a single institution experience

OBJECTIVE

To determine the incidence of long term lymphadenectomy complications in primary surgery for endometrial cancer and to elucidate risk factors for these complications.

METHODS

A retrospective chart review was carried out for all patients with endometrial cancer managed at Parma University Hospital Unit of Gynecology and Obstetrics between 2010 and 2016. Inclusion criteria were surgical procedure including hysterectomy and lymphadenectomy (pelvic or pelvic and aortic). We identified patients with postoperative lymphocele and lower extremity lymphedema. Logistic regression analysis was used to identify predictive factors for postoperative complications.

RESULTS

Of the 249 patients tested, 198 underwent pelvic lymphadenectomy (79.5%), and 51 (20.5%) of those underwent both pelvic and para-aortic lymphadenectomy. Among the 249 patients, 92 (36.9 %) developed lymphedema while 43 (17.3%) developed lymphocele. Multivariate analysis showed that addition of para-artic lymphadenectomy was an independent predictor for both lymphedema (odds ratio (OR) 2.764, 95% confidence interval (CI) 1.023 to 7.470) and lymphocele (OR 5.066, 95% CI 1.605 to 15.989). Moreover, postoperative adjuvant radiotherapy (OR 2.733, 95% CI 1.149 to 6.505) and identification of any positive lymph node (OR 19.391, 95% CI 1.486 to 253.0) were significantly correlated with lymphedema, while removal of circumflex iliac nodes (OR 8.596, 95% CI 1.144 to 65.591) was associated with lymphoceles occurrence.

CONCLUSION

Although sentinel lymph node navigation is a promising option, lymphadenectomy represents the primary treatment in many patients with endometrial cancer. However, comprehensive nodal dissection remains associated with a high rate of long term complications, such as lymphedema and lymphocele. Avoiding risk factors that are related to the development of these postoperative complications is often difficult and, therefore, the strategy to assess lymph nodal status in these women must be tailored to obtain the maximum results in terms of oncological and functional outcome.

Psychophysiological Adjustment to Ovarian Cancer: Preliminary Study on Italian Women Condition

This study aimed to evaluate the psychological and physiological adjustment in a sample of Ovarian Cancer survivors. For all we know, this is the first time that such analysis has been performed in Italy. We assessed psychological adjustment along with physiological adjustment, measured through the basal Heart Rate Variability at rest. We assessed 38 women overall, aged 29-80 years, in follow up for ovarian cancer. Each participant filled a psycho-oncological record, Multidimensional Scale of Perceived Social Support, Derridford Appearance Scale-59, Mental Adjustment to Cancer and EORTC Quality of Life Questionnaire LQ-30 Version 3.0. For each participant, we recorded Heart Rate Variability (5 min). These women have shown a high rate of perceived general social support (Me = 5.93) but they seem to have some general concern about their appearance (Me = 85.97, SD = 24.4). They have also shown a rather good total Quality of Life (QL2 Me = 66.32) with specific difficulties in emotional functioning (EF; Me = 69.19). Heart Rate Variability values, however, were lower of nearly 50% when compared to normative values. These women, then, seem to drag concerns and difficulties, in particular linked to the acceptance of their condition. Surprisingly enough, the best adjustment in these women seems to be related to the worst starting conditions. It is possible to suggest that the extremely negative conditions force these women to face cancer openly, as well as their condition of cancer survivors, pushing them "moving on" more than "trying to get back".

Tubal ectopic pregnancy: our experience from 2000 to 2013

In this paper we summarize our experience in diagnosis and treatment of 402 retrospectively collected tubal EP and review the most recent topics from the literature. Systemic Methotrexate (MTX) was effective in 56 out of 65 patients (failure rate 13.8%), in whom hCG level was significantly lower when compared to the failure group (p&lt;0,05); we performed 299 salpingectomies, 297 of whom through laparoscopic approach. MTX single-dose is safe and effective in eligible patients; surgery represents the treatment of most of the EPs, mainly through laparoscopic approach.

Conservative treatment for interstitial monochorionic twin pregnancy: case report and review of the published work

Interstitial pregnancy is considered one of the most hazardous types of ectopic pregnancies, with a mortality rate of 2-2.5%. We describe a case of a viable monochorionic twin pregnancy in a 35-year-old woman successfully treated with systemic methotrexate associated with bilateral uterine arteries' embolization. β-hCG was undetectable 67 days after the first administration of methotrexate and the ultrasonography performed on day 67 showed the remnant of the gestational sac in the right uterine horn, a thin endometrium and a normal myometrial vascularization. Conservative treatment allowed us to avoid surgical treatment and to preserve the patient's fertility.

Randomised prospective study of abdominal wall closure in patients with gynaecological cancer

BACKGROUND

Median laparotomy is the most common approach to the abdominopelvic cavity in patients with gynaecological tumours.

AIMS

The primary endpoint of the study was to evaluate the onset of incisional hernia. The secondary endpoint was to evaluate the onset of infection, wound dehiscence, wound infection, and scar pain during the post-operative period.

METHODS

A total of 191 patients were eligible for the study. They were divided into three groups. Group A underwent en bloc closure of the peritoneum and fascia with Premilene suture, Group B en bloc closure of the peritoneum and fascia with Polydioxanone suture, and Group C separate closure of the peritoneum and fascia with single stitches of Ethibond suture. Statistical analysis was performed using the Statistical Software Package for Social Sciences 12.0.

RESULTS

Group A and Group B comprised 63 patients, and Group C included 65 patients. The three groups proved homogeneous on statistical analysis (P > 0.05). The statistical analysis did not reveal significant differences between the different suture types and techniques with respect to the incidence of incisional hernia (P > 0.05).

CONCLUSION

In our study, the incidence of incisional hernia was 8%. Randomised patients were homogeneous for sample size and risk factors. No significant differences were found between suture types or techniques. Currently, there is no suture material or technique that can be considered superior to others. When possible, we believe that the best way to prevent incisional hernia is to preserve the integrity of the abdominal wall using minimally invasive techniques.

Uterine tumors resembling ovarian sex cord tumors: a case report of conservative management in young women

Uterine tumors resembling ovarian sex cord tumors (UTROSCT) are distinguished into two separate groups: endometrial stromal tumors with sex cord-like elements (Group I), which have an unfavorable prognosis; and UTROSCT proper (group II), with more than 40% sex cord-like differentiation and less endometrial component, which are biologically less aggressive than the tumors of the other group. We report the case of a young woman with UTROSCT treated by minimally invasive hysteroscopic surgery. This is one of the few cases reported in the literature that have been managed conservatively.

A perspective study on correlation between HPV DNA and lymph nodes in surgically treated cervical carcinoma patients. Preliminary data

The purpose of this study was to analyze the presence of HPV DNA in lymph nodes in patients with cervical cancer.

STUDY DESIGN

A prespective study was performed on a total of 18 patients with cervical cancer in FIGO Stage I-II. The surgical procedure consisted of systematic pelvic lymphadenectomy with removal of the common/external/internal (obturator) iliac lymph node chains, followed by radical hysterectomy depending on the clinical stage, or by Piver's type II radical laparohysterectomy for Stage IA2 carcinoma and Piver's type-III laparohysterectomy for Stage IB or Stage II carcinoma. After removal by a technique not yet described in the literature, the lymph nodes were processed directly in the operating room. HPV DNA testing was done using a cytobrush device. At the end of this operation, the lymph nodes were sent to the hospital's pathologist for metastasis detection.

RESULTS

The correlation between a positive HPV DNA test in the cervix and lymph node metastasis was non significant (p < 0.63). By contrast, the correlation between a positive HPV DNA test in the lymph nodes and lymph node metastasis was highly significant (p < 0.005), as was the correlation between positive HPV DNA tests in the cervix and lymph nodes (p < 0.005). Finally, the correlation between disease stage and positive HPV DNA testing in the lymph nodes was also significant (p < 0.05).

CONCLUSIONS

In conclusion, the technique that we used for HPV DNA extraction appears safe and reproducible. The results are comparable with, if not better, than those obtained with other techniques reported in the literature. The presence of HPV DNA in the lymph nodes is probably an early indicator of metastasis and as such it could be used as a predictor of relapse. Normally untreated patients who have this marker could then receive adjuvant therapy.

Uterine smooth muscle tumor of uncertain malignant potential: a three-case report

Based on the degree of cytologic atypia, mitotic activity, and other features, uterine smooth muscle tumors have historically been grouped into two classes: benign leiomyomas and malignant leiomyosarcomas. However, this separation holds true more in principle than in practice because the tumor's biological potential may not always be determined with certainty, complicating diagnosis, and therapy. We report three cases of patients with uterine smooth muscle tumors of uncertain malignant potential. Surgery was radical in two and conservative in one. During the follow-up, one patient developed diffuse lung metastases. The two other patients have not shown any signs of relapse to date. Uterine smooth muscle tumors of uncertain malignant potential may have an unpredictable clinical course and may metastasize to seemingly low-grade neoplasms in distant sites even after several years and even in the absence of important negative prognostic predictors, such as coagulative tumor cell necrosis. At present, no final consensus has been reached on the choice of the best strategy for surgery and adjuvant therapy

Preoperative transvaginal ultrasonography and intraoperative gross examination for assessing myometrial invasion by endometrial cancer

OBJECTIVE

Endometrial cancer is the most common gynecologic malignancy. The cornerstone of treatment remains surgery according to International Federation of Gynecology and Obstetrics staging. The aim of this study was to evaluate the concordance between myometrial infiltration detected by ultrasonography and gross examination with respect to definitive histologic examination and to select a population in which lymphadenectomy could be excluded. We also evaluated the concordance for the degree of tumor differentiation between diagnostic biopsy and final histologic results.

METHODS

Our study included 75 patients with International Federation of Gynecology and Obstetrics stage I endometrial cancer. We evaluated preoperative and definitive grading and myometrial infiltration detected by ultrasonography and gross examination. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the procedures under study were determined with the Bayes theorem. To determine the predictive value of preoperative transvaginal ultrasonography and intraoperative gross examination for myometrial invasion, we used a multiple logistic regression model with a statistical software package.

RESULTS

Our study showed 60% concordance between biopsy and histologic results. In 80% of the cases with discordant results, the tumor was undergraded. Ultrasonography had diagnostic accuracy of 73%, whereas gross examination correctly determined myometrial invasion in 82.6% of the patients, with sensitivity of 62% and specificity of 79%.

CONCLUSIONS

Preoperative transvaginal ultrasonography and macroscopic gross examination appear to be simple, fast, and reliable methods to predict in myometrial invasion in patients with a low risk for lymph node metastasis, for which lymphadenectomy can reasonably be avoided.

Human papilloma virus (HPV) status, p16INK4a, and p53 overexpression in epithelial malignant and borderline ovarian neoplasms

This investigation is the first to evaluate simultaneously human papilloma virus (HPV) status, p16(INK4a), and p53 immunoreactivity in epithelial ovarian neoplasms. The results were analyzed and correlated with histological type, histological grade, and survival of patients. Subtypes considered are papillary serous and mucinous. Polymerase chain reaction (PCR) analysis, performed in our previous study, had already demonstrated a small number of HPV-positive epithelial ovarian neoplasms. No significant correlation was found between the presence of HPV DNA and subtypes of ovarian neoplasms; thus, HPV cannot be considered responsible for epithelial ovarian neoplasm. Since p16 immunoreactivity was present in many other HPV-negative cases of epithelial ovarian neoplasms, this study suggests that p16 overexpression in some neoplasms of the female genital tract is not related to HPV carcinogenesis. A higher p53 expression rate observed between borderline and malignant serous tumors and between serous and mucinous neoplasms can confirm a recent dualistic model of ovarian carcinogenesis. According to this theory, low-grade serous carcinomas (serous intraepithelial carcinomas, serous borderline neoplasm, and ovarian mucinous neoplasms) (type I tumors) develop from mutations of KAS and BRAF, while high-grade serous carcinomas (type II tumors) develop from mutation of p53. In malignant neoplasms, for univariate analysis, patient survival seems to be related to p53, strong and diffuse p16 overexpression, and the stage of development of neoplasms at the diagnosis. In multinomial logistic regression, used to evaluate the role of staging, grading, p16 and p53 immunopositivity as predictor variables of unfavorable outcome of the disease, only p16 positivity was significantly related to the poor prognosis of the cancer.

P16INK4a overexpression independent of Human Papilloma Virus (HPV) infection in rare subtypes of endometrial carcinomas

In the current study, we evaluated p16 expression in rare subtypes of endometrial carcinomas, whose HPV status has been previously examined in order to establish the role of this protein in their pathogenesis. These rare subtypes of endometrial carcinomas are primary squamous endometrial carcinoma (ESCC), endometrial mucinous microglandular adenocarcinoma (EMMA), and endometrial transitional cell carcinoma (ETCC). All tissues, obtained at the time of hysterectomy, were fixed in 10% phosphate-buffered formalin and embedded in paraffin. Serial sections were made for hematoxylin and eosin staining and for immunohistochemistry. Although a previous PCR study has demonstrated that none of these neoplasms showed any signal for HPV DNA, these malignancies did display immunoreactivity for P16(INK4a). In ESCC, P16(INK4a) immunoreactivity was diffuse in 100% of neoplastic cells. In two cases of EMMA, positivity for P16INK4a was zonal. In ETCC, scattered cells were positive for P16INK4a protein. These findings suggest that alteration of p16 could play an etiologic role, without any association to HPV infections, in these rare endometrial carcinomas. However, in our view, other cases of these rare malignancies should be investigated in order to confirm this hypothesis.

Transitional Cell Carcinoma of the Endometrium Associated With Benign Ovarian Brenner Tumor

Transitional cell carcinoma of the endometrium (TCCE) is a subtype of endometrial carcinoma, characterized by a prominent papillary pattern, resembling the papillary carcinoma of the urothelium. This neoplasm is very rare, with only 13 cases reported in the international literature. In this paper, a new case of TCCE associated with benign ovarian Brenner tumor is described. This association is extremely rare, with only 1 other case reported. A review of the literature is performed to delineate the clinico pathologic features of this malignancy. Moreover, immunohistochemical and molecular studies are carried out in the effort to establish the phenotype and etiology of this rare neoplasm. The molecular study, by polymerase chain reaction (PCR) failing to reveal the presence of HPV DNA, demonstrates that neither the TCCE nor the ovarian Brenner tumor is caused by an HPV infection. The association of TCCE with benign ovarian Brenner tumor could be a coincidental event. Conversely, this finding could be the manifestation of a multicentric metaplastic process (neometaplasia), involving both the coelomic epithelium of the ovary and the Mullerian epithelium of the uterus, or the evidence of "field effect" that manifests differently at different anatomical sites. In our view, other cases of TCCE associated with ovarian Brenner tumor should be reported to confirm the last 2 hypotheses.

Villoglandular Adenocarcinoma of the Cervix

In this paper, we report 2 new cases of villoglandular papillary adenocarcinoma (VGPA) of the cervix, a rare, well-differentiated form of cervical adenocarcinoma. Both patients were without medical complications or history of oral contraceptive use and were nonsmokers. Extended hysterectomy was performed in both cases. Morphological criteria for a correct pathological diagnosis were emphasized. Immunohistochemical analysis was performed to clarify the phenotype of the neoplasms. Moreover, for the first time, we probed to establish if VGPA could be correlated to human papilloma virus (HPV) and herpes virus (HSV) types 1 and 2, using polymerase chain reaction amplification of tumoral DNA. Both neoplasms showed positivity for B72.3, Ca-125, carcinoembryonic antigen, keratin 7, and p16(INK4a) protein. Vimentin, P53, estrogen, and progesterone receptors, instead, were negative. Molecular study by polymerase chain reaction amplification of tumor DNA revealed a strong positive signal for HPV-DNA and no signal for HSV-DNA. It is reasonable to conclude that our cases of VGPA, in accordance with other examples reported in literature, are due to HPV infection. Behavioral cofactors, such as HSV infection (types 1 and 2), oral contraceptive use and smoking, involved in the pathogenesis of other cervical malignancies, can be excluded for the present cases.

Detection of human papillomavirus in organs of upper genital tract in women with cervical cancer

In this study, we evaluated the presence of human papillomavirus (HPV) DNA in organs of the female upper genital tract, using nine hysterectomy and salpingo-oophorectomy specimens affected by HPV-positive invasive cervical carcinomas, to establish if cervical HPV infection can spread to upper tracts of the female genital system. HPV DNA was evaluated by polymerase chain reaction (PCR) in all cervical carcinomas as well as in all tracts of the genital system. Then, these data were compared with the results obtained from PCR study of five other hysterectomy and salpingo-oophorectomy specimens (control cases). The criteria used for selection of the control cases were informed consent of the patients for research at the time of surgery, absence of neoplasms, absence of any anatomic lesion caused by HPV in cervix, and external genitalia. All selected cases were squamous cervical carcinomas. PCR analysis revealed HPV DNA in all cases of cervical carcinoma. The HPV DNA was detected as weak positivity on PCR analysis in other organs of the genital system. However, the distribution of HPV DNA varied in the various cases and in the different tracts of the same hysterectomy and salpingo-oophorectomy specimen. We believe that the HPV DNA, detected as a weakly positive signal, in the upper genital tract of patients who have a cervical squamous carcinoma could be a reflection of a latent HPV infection, as well as a sign of the existence of micrometastases containing HPV DNA, which cannot be detected by conventional histologic techniques.

Postmenopausal status, hypertension and obesity as risk factors for malignant transformation in endometrial polyps

OBJECTIVES

We analyzed clinical data and pathological features of six cases of malignant endometrial polyps, to compare these with other examples reported in literature and to define the features of endometrial cancer arising in polyps. Moreover, to clarify the mechanisms of carcinogenesis in malignant endometrial polyps we examined the expression of cyclooxygenase-2 (COX-2), P53 and Ki 67 and their relationships with clinicopathologic characteristics.

METHODS

The surgical pathology files of the Pathology Department of Parma University were searched for cases of endometrial polyps with nests of endometrial carcinomas, from the years 2002-2005. Clinical records, histological slides of endometrial curetting, hysterectomy with salpingo-oophorectomy specimens and pelvic lymph nodes were reviewed in each case. The main pathological features analyzed were histological types of endometrial cancer and the stage of development of neoplasm. The presence of other malignancies in the genital tract were also considered. Immunohistochemical staining was done using antibodies COX-2, p53 and Ki 67.

RESULTS

In our study, all malignant endometrial polyps had been detected in postmenopausal women. The majority of our patients with malignant endometrial polyps had risk factors for the development of endometrial carcinoma such as hypertension, obesity and unopposed estrogen therapy. Unlike other studies, no patients had a history of previous breast carcinoma and Tamoxifen treatment. The most common subtypes of endometrial carcinoma in malignant polyps are endometrioid carcinoma and serous papillary carcinoma. Endometrial carcinoma arising in endometrial polyps is an early endometrial carcinoma with good prognosis, except for papillary serous carcinoma, which can be associated with multiple omental involvement, despite low stage of development in the uterus. Immunohistochemical study showed that COX-2 expression was found in cytoplasm of tumor cells and this was elevated in all cases, independently of the grade and the stage of development of the malignancy, histological subtype and deep invasion of myometrium. P53 and Ki 67 expression, detected in the nuclei of neoplastic cells, was not correlated with COX-2 immunoreactivity, but these markers were associated with more advanced stage, grading, and histologic subtypes of tumor.

CONCLUSIONS

Postmenopausal status, hypertension, obesity could all be considered as risk factors for carcinomatous transformation within endometrial polyps in women without a history of breast carcinoma and Tamoxifen treatment. However, our series is small (only six cases considered) and further studies are necessary to confirm this hypothesis. In the current study, immunohistochemical data reveal that COX-2 expression may be associated with the carcinogenesis in endometrial carcinomas arising in endometrial polyps, but this antibody is not correlated with tumor aggressiveness, P53 and Ki 67 expression. P53 and Ki 67 overexpression, instead, are associated with advanced stage, histologic subtype and deep myometrial invasion of neoplasm.

Metastatic extragenital neoplasms to the uterus: a clinicopathologic study of four cases

The aim of this study was to elucidate the clinicopathologic features, the differential diagnostic problems, and the prognostic consequences of patients with metastatic extragenital malignancies to uterus. The patients with metastatic extragenital malignancies to the uterus were evaluated. We considered the metastases in non-genital tract organs at diagnosis of primary neoplasm, the distribution of the metastases in the uterus, and the presence of concomitant metastases in other genital and non-genital tract organs. There were four cases of metastatic extragenital malignancies to the uterus. The breast was the most frequent primary site (two cases: 50%). The other two primary tumors were adenocarcinoma of the cecum and malignant melanoma of the skin. The diagnosis was facilitated by clinical history, revealing the previous primary neoplasm, and by specific immunohistochemical study. Almost all the patients died from disseminated disease. Thus, the prognosis of metastatic extragenital malignancies to the uterus alone or simultaneously to the uterus and other organs of the genital tract is poor. Thus, the metastases to the uterus and to other organs of the genital tract can be considered a preterminal event.

Epidoxorubicin versus no treatment as consolidation therapy in advanced ovarian cancer: results from a phase II study

To compare the effect of epidoxorubicin given for 4 months versus no treatment in the survival of patients with advanced ovarian cancer and complete pathologic response after first-line surgery and chemotherapy with platinum-based schedules, we conducted a multicenter randomized clinical trial. Patients with histologic diagnosis of epithelial ovarian cancer FIGO stage III or IV at first diagnosis; complete pathologic response at second-look laparotomy/laparoscopy or complete clinic response; and those who have had first-line therapy including surgery and one regimen containing cisplatin or carboplatinum were eligible for the study and were randomly allocated to epidoxorubicin 120 mg/sqm or no treatment. A total of 64 women were allocated to epidoxorubicin and 74 to no treatment. There were 20 and 19 deaths, respectively, in the epidoxorubicin and no-treatment groups. The 3-year percent overall survival was 79.0% and 78.7%, respectively, in the no-treatment and epidoxorubicin groups (log-rank test, P= 0.93).

Endometrial mucinous microglandular adenocarcinoma: morphologic, immunohistochemical features, and emphasis in the human papillomavirus status

We report two cases of endometrial microglandular adenocarcinoma, a rare neoplasm, which, in its morphologic features, mimics cervical microglandular hyperplasia and mucinous proliferations of endometrium. The criteria for a correct pathological diagnosis, such as clinical, morphologic, and immunohistochemical data, are emphasized. For the first time, we probed to establish whether endometrial mucinous microglandular adenocarcinoma could be correlated to human papilloma virus (HPV) infection by using polymerase chain reaction amplification (PCR) of tumoral DNA. Similar to previous studies reported in the literature, the present lesions, occurring in postmenopausal women, immunohistochemically showed positivity for B72.3, Ca 125, CEA, Vimentin, estrogen and progesterone receptors, and negativity for p53. Molecular study by PCR amplification of tumor DNA showed no signal for HPV DNA in any of these cases; thus, this variant of endometrial carcinoma is not caused by the HPV infection, but probably by other pathogenetic mechanisms, such as an accumulation of the mutations, which arrive in old age or as the consequence of a peculiar hormonal situation.

Epidoxorubicin versus no treatment as consolidation therapy in advanced ovarian cancer: results from a phase II study

To compare the effect of epidoxorubicin given for 4 months versus no treatment in the survival of patients with advanced ovarian cancer and complete pathologic response after first-line surgery and chemotherapy with platinum-based schedules, we conducted a multicenter randomized clinical trial. Patients with histologic diagnosis of epithelial ovarian cancer FIGO stage III or IV at first diagnosis; complete pathologic response at second-look laparotomy/laparoscopy or complete clinic response; and those who have had first-line therapy including surgery and one regimen containing cisplatin or carboplatinum were eligible for the study and were randomly allocated to epidoxorubicin 120 mg/sqm or no treatment. A total of 64 women were allocated to epidoxorubicin and 74 to no treatment. There were 20 and 19 deaths, respectively, in the epidoxorubicin and no-treatment groups. The 3-year percent overall survival was 79.0% and 78.7%, respectively, in the no-treatment and epidoxorubicin groups (log-rank test, P= 0.93).

Metastatic extragenital neoplasms to the uterus: a clinicopathologic study of four cases

The aim of this study was to elucidate the clinicopathologic features, the differential diagnostic problems, and the prognostic consequences of patients with metastatic extragenital malignancies to uterus. The patients with metastatic extragenital malignancies to the uterus were evaluated. We considered the metastases in non–genital tract organs at diagnosis of primary neoplasm, the distribution of the metastases in the uterus, and the presence of concomitant metastases in other genital and non–genital tract organs. There were four cases of metastatic extragenital malignancies to the uterus. The breast was the most frequent primary site (two cases: 50%). The other two primary tumors were adenocarcinoma of the cecum and malignant melanoma of the skin. The diagnosis was facilitated by clinical history, revealing the previous primary neoplasm, and by specific immunohistochemical study. Almost all the patients died from disseminated disease. Thus, the prognosis of metastatic extragenital malignancies to the uterus alone or simultaneously to the uterus and other organs of the genital tract is poor. Thus, the metastases to the uterus and to other organs of the genital tract can be considered a preterminal event.

Retzius' space haematoma after spontaneous delivery: a case report

We report a case of a haematoma of the Retzius space after spontaneous uncomplicated delivery. In the postpartum period, the patient complained of urinary retention and pain in the hypogastric region radiating to her left hip and leg. The ultrasound examination showed the presence of 160 x 100 x 80 mm confluent solid and liquid areas with peripheral vascularization. At exploratory laparotomy a haemorrhagic infiltration was found in Retzius' space and the anterior wall of the bladder, which appeared thickened and swollen below the peritoneum. We tried to drain the haematoma, however, we failed to drain it completely because of the large blood infiltration in the bladder wall. Clinical and ultrasound follow-up examinations showed a progressive reduction of the haematoma which completely disappeared nine months later. The haemodynamic changes occurring during pregnancy and labour, associated with strong mechanical stress, seem to be among the major causative factors of haematoma formation. Moreover, the venous load in the pelvic vascular system is increased during pregnancy; a stress-induced increase in venous blood pressure might play a prominent role, especially in cases of venous ectasia, where the resistance of blood vessel walls is reduced. Intraoperative evidence seemed to suggest a haemorrhage secondary to the rupture of the venous vessels in the Santorini plexus. The rupture was probably caused by the thrust of the fetal head, associated with abnormality or fragility of the blood vessels, or by some pathologic changes occurring in the anatomical structures during pregnancy, which could not be accurately defined because of the severity and degree of the haematoma infiltration found intraoperatively.

Endometrial cancer in patients with preoperative diagnosis of atypical endometrial hyperplasia

OBJECTIVE

Atypical endometrial hyperplasia (AEH) has been associated with the presence of concomitant endometrial carcinoma (EC). The aim of this study is to examine the frequency of coexisting endometrial carcinoma when atypical endometrium hyperplasia was found upon biopsy. We also evaluated the influence of preoperative diagnostic techniques (pipelle and dilation and curettage (D&C)), and the value of transvaginal ultrasound in detecting unexpected tumor invasion.

STUDY DESIGN

Between January 1992 and December 2003, at the Department of Obstetrics and Gynecology, University of Parma, and Policlinico S. Matteo, Pavia, 70 consecutive patients subjected to total hysterectomy with a histological diagnosis of AEH were retrospectively selected. 52/70 patients underwent vaginal hysterectomy, with bilateral salpingo-oophorectomy (BSO) whereas 18/70 had abdominal hysterectomy with BSO within 8 weeks since the diagnosis of AEH.

RESULTS

We found in 30 of the 70 patients with atypical endometrial hyperplasia in the biopsy coexisting endometrial carcinoma (43%). No differences in diagnostic accuracy between the pipelle method and D&C were found.

CONCLUSION

Transvaginal ultrasound was not a feasible method for predicting EC. After a follow-up of an average of 5 years there was, neither in the abdominal operated patients nor in the vaginal operated patients, a recurrence of disease.

Vulvar Acantholytic Squamous Carcinoma: A Case Report With Immunohistochemical and Molecular Study

Acantholytic carcinoma is a subtype of squamous carcinoma, characterized by tubular and alveolar formations as a consequence of the acantholysis. We report a case of vulvar squamous acantholytic carcinoma (VSAC) in a 69-year-old woman, who was admitted to our institution for vulvar pruritus and the presence of a large, bilateral, exophytic, and ulcerated lesion, measuring 7 x 8 cm. The patient had never received vulvar or pelvic radiation therapy. Pathological examination with an immunohistochemical study showed features of VSAC and high p16 protein expression. Molecular study by polymerase chain reaction amplification of DNA tumor revealed a weakly positive signal for human papillomavirus. In conclusion, our case, which is the first case of VSAC with polymerase chain reaction analysis and immunohistochemical expression of p16 protein, suggested that this neoplasm could be related to human papillomavirus infection.

Radioguided sentinel lymph node detection in vulvar cancer

Lymph node status is the most important prognostic factor in vulvar cancer. Histologically, sentinel nodes may be representative of the status of the other regional nodes. Identification and histopathologic evaluation of sentinel nodes could then have a significant impact on clinical management and surgery. The aim of this study was to evaluate the feasibility and diagnostic accuracy of sentinel lymph node detection by preoperative lymphoscintigraphy with technetium-99 m-labeled nanocolloid, followed by radioguided intraoperative detection. Nine patients with stage T1, N0, M0, and 11 patients with stage T2, N0, M0 squamous cell carcinoma of the vulva were included in the study. Only three cases had lesions exceeding 3.5 cm in diameter. Sentinel nodes were detected in 100% of cases. A total of 30 inguinofemoral lymphadenectomies were performed, with a mean of 10 surgically removed nodes. Histological examination revealed 17 true negative sentinel nodes, 2 true positive, and 1 false negative. In our case series, sentinel lymph node detection had a 95% diagnostic accuracy, with only one false negative. Based on literature evidence, the sentinel node procedure is feasible and reliable in vulvar cancer; however, the value of sentinel node dissection in the treatment of early-stage vulvar cancer still needs to be confirmed.

Radioguided sentinel lymph node detection in vulvar cancer

Lymph node status is the most important prognostic factor in vulvar cancer. Histologically, sentinel nodes may be representative of the status of the other regional nodes. Identification and histopathologic evaluation of sentinel nodes could then have a significant impact on clinical management and surgery. The aim of this study was to evaluate the feasibility and diagnostic accuracy of sentinel lymph node detection by preoperative lymphoscintigraphy with technetium-99 m–labeled nanocolloid, followed by radioguided intraoperative detection. Nine patients with stage T1, N0, M0, and 11 patients with stage T2, N0, M0 squamous cell carcinoma of the vulva were included in the study. Only three cases had lesions exceeding 3.5 cm in diameter. Sentinel nodes were detected in 100% of cases. A total of 30 inguinofemoral lymphadenectomies were performed, with a mean of 10 surgically removed nodes. Histological examination revealed 17 true negative sentinel nodes, 2 true positive, and 1 false negative. In our case series, sentinel lymph node detection had a 95% diagnostic accuracy, with only one false negative. Based on literature evidence, the sentinel node procedure is feasible and reliable in vulvar cancer; however, the value of sentinel node dissection in the treatment of early-stage vulvar cancer still needs to be confirmed.

Single-dose methotrexate for ectopic pregnancy treatment: preliminary data

BACKGROUND AND AIM OF THE WORK

Our purpose was to evaluate the efficacy of a single-dose of MTX for ectopic pregnancy treatment in a sample of patients carefully selected according to strict inclusion criteria.

METHODS

11 patients that matched the inclusion criteria were enrolled.

RESULTS

Beta-hCG at diagnosis averaged 1349 mIU/ml out of the 11 treated patients, 10 (90%) received a single dose of MTX and had a time of EP resolution averaging 27.3 days. The remaining patient received an additional dose of MTX, equal to the start dose, with a time resolution of 35 days.

CONCLUSIONS

This study provides evidence of the efficacy of MTX in EP treatment, both as therapy and as a form of clinical management: the successful medical management of EP, defined as beta-hCG levels becoming negative after administration of one or more MTX doses, was obtained in all treated cases.

Primary squamous cell carcinoma of the endometrium: a case report with immunohistochemical and molecular study

BACKGROUND

In this paper, we report a case of primary squamous cell carcinoma of the endometrium (PSCCE) with immunohistochemical and molecular study to evaluate the phenotype and to define the etiopathogenesis of this tumor.

CASE HISTORY

A 72-year-old woman was admitted to the Department of Obstetric and Gynecology for weight loss and pelvic mass. Abdominal ultrasonography disclosed the abdominopelvic mass with solid, cystic, and calcified areas. The patient underwent exploratory laparotomy. Intraoperative findings showed an enlarged uterus with perforation of its wall. The surface of omentum was covered with small white nodules. Pathological examination showed features of PSCCE. Immunohistochemical analysis with antibodies for estrogen and progesterone receptors disclosed negativity of neoplastic elements. Immunostaining with p53 tumor-suppressor protein showed the mutation of p53 tumor-suppressor protein as a strong nuclear positivity. Molecular study by polymerase chain reaction (PCR) amplification of tumor DNA did not show any signal for human papilloma virus (HPV) DNA.

CONCLUSION

In summary, unlike the example reported in the literature by others, in the present case we demonstrated that PSCCE is not due to HPV infection, but probably to other pathogenetic mechanisms, which cause a mutation of p53 tumor-suppressor gene. Thus, it is reasonable to conclude that both HPV infection and unclear carcinogenic factors, responsible of p53 tumor-suppressor gene mutation, may cause PSCCE.