Quality of life after extended pelvic exenterations

BACKGROUND

The aim of the study was to compare health-related quality of life (QoL) and oncological outcome between gynaecological cancer patients undergoing pelvic exenteration (PE) and extended pelvic exenteration (EPE). EPEs were defined as extensive procedures including, in addition to standard PE extent, the resection of internal, external, or common iliac vessels; pelvic side-wall muscles; large pelvic nerves (sciatic or femoral); and/or pelvic bones.

METHODS

Data from 74 patients who underwent PE (42) or EPE (32) between 2004 and 2019 at a single tertiary gynae-oncology centre in Prague were analysed. QoL assessment was performed using EORTC QLQ-C30, EORTC CX-24, and QOLPEX questionnaires specifically developed for patients after (E)PE.

RESULTS

No significant differences in survival were observed between the groups (P > 0.999), with median overall and disease-specific survival in the whole cohort of 45 and 49 months, respectively. Thirty-one survivors participated in the QoL surveys (20 PE, 11 EPE). No significant differences were observed in global health status (P = 0.951) or in any of the functional scales. The groups were not differing in therapy satisfaction (P = 0.502), and both expressed similar, high willingness to undergo treatment again if they were to decide again (P = 0.317).

CONCLUSIONS

EPEs had post-treatment QoL and oncological outcome comparable to traditional PE. These procedures offer a potentially curative treatment option for patients with persistent or recurrent pelvic tumour invading into pelvic wall structures without further compromise of patients´ QoL.

Diagnostic pitfalls in ovarian androgen-secreting (Leydig cell) tumours: case series

Leydig cell tumours of the ovary are rare and represent a diagnostic challenge not only due to their sporadic incidence but also due to the seemingly normal imaging. We present three cases of pre- and postmenopausal women who were presented with severe clinical signs of hyperandogenism where modern imaging modalities (including computed tomography (CT), magnetic resonance imaging (MRI) and positron-emission tomography combined with computed tomography (PET-CT)) failed to identify the tumour. Two patients underwent non-expert ultrasound, CT and MRI examination with uniform conclusion that ovaries are of normal appearance. One of the two patients even had a PET-CT performed, which was inconclusive. Our case reports show the importance of examination by specialists with established skills in gynaecologic ultrasonography in the diagnosis of the Leydig cell tumours. The most useful diagnostic tool seems to be the combination of age (postmenopause), symptoms (onset of hirsutism and virilisation), high total testosterone plasma values and expert sonography. On ultrasound, these tumours are unilateral, usually small, solid intraovarian nodules of a slightly increased echogenicity in contrast to the surrounding ovarian tissue, delineated by abundant perfusion with an enhanced vascularity. The appropriate setting of the sensitive colour Doppler is crucial for the detection of intraovarian Leydig cell tumour. Impact statement What is already known on this subject? A diagnosis of Leydig cell tumours is based on ultrasound performed by a trained examiner or by MRI. CT or PET/CT are not among the primary methods of choice. According to the results of imaging investigations surgical treatment is planned. Because these tumours are usually benign and have a good prognosis the unilateral salpingo-oophorectomy is a standard procedure. What do the results of this study add? Our case series show how difficult it can be to establish the diagnosis of Leydig cell tumours by imaging, including transvaginal ultrasound, the most frequently recommended diagnostic tool. We demonstrate in three cases how easily a small hyperechogenic tumour can be overseen or interchanged for a different gynaecological pathology if transvaginal scan is not performed by an experienced examiner trained in sonographic features of gynaecologic neoplasms. What are the implications of these findings for clinical practice and/or further research? This case series demonstrate how important it is to see the patient in the whole complexity with their medical history, proper clinical symptoms evaluation, laboratory test and not to rely solely just on sophisticated high-end investigations, such as the PET-CT, a CT and an MRI. It also emphasises the importance of specialists with established skills in gynaecologic ultrasonography. Further effort should be made to define the resources for the appropriate training of such sonographers.

Endometriosis in pregnancy - diagnostics and management

OBJECTIVE

Endometriosis in pregnancy predominantly tends to regress or to stay stable but small part of endometriomas and nodules of deep infiltrating endometriosis may undergo the process of decidualization. Therefore, the foci of endometriosis enlarge their volume and change their structure due to cellular hypertrophy and stromal edema associated with higher vascularization caused by the hormonal changes in pregnant women. Consequently, these totally benign lesions may resemble malignant tumors in ultrasound examination.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague.

METHODS

A literature review of published data on decidualization of endometriosis.

RESULTS

Majority of decidualized ovarian endometriomas is asymptomatic so it is mostly accidentally found during the routine ultrasound check-ups within the frame of perinatologic screening. The rounded, smooth, highly vascularized solid papillary projections in internal wall of endometroid cysts are the most specific characteristics of decidualization. If ultrasound simple rules are not applicable or show probable malignancy, the pregnant patient should be referred to a tertiary center for expert ultrasound assessment. Magnetic resonance is indicated in cases of uncertain ultrasound findings, because it can clarify the diagnostics due to its high accuracy in detection of products of blood degradation and ability of diffusion-weighted imaging to recognize lower tissue cellularity of benign decidualized endometriomas in comparison to malignant ovarian tumors.

CONCLUSION

If the imaging methods confirm supposed decidualized endometriosis, watch and wait management based on regular ultrasound examinations during the whole pregnancy and after childbed is recommended. The regression of the tumor size and disappearance of the solid portions within endometriomas is expected after delivery. Decidualized endometriosis is rarely a source of gestational or obstetrical complications demanding acute surgical intervention. Elective surgical procedures in pregnant women are indicated only if expert ultrasound or magnetic resonance imaging assess the masses as border-line or invasive tumors (carcinomas) and in cases of suspicious changes of the originally presumed benign cysts during the surveillance.

Diagnosis of endometriosis 3rd part - Ultrasound diagnosis of deep endometriosis

OBJECTIVE

To summarise the current knowledge and trends in the diagnosis of deep endometriosis.

DESIGN

Review article.

SETTING

Centre for diagnostics and treatment of endometriosis and Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Gynaecology and Obstetrics, Burton Hospitals NHS, United Kingdom.

METHODS

Literature review.

RESULTS

Deep endometriosis (DE) in the pelvis is divided into lesions in the anterior and posterior compartment. In the anterior compartment DE infiltrates bladder and ureters, while in the posterior compartment it is mostly uterosacral ligaments, rectum, rectosigmoid and sigmoid colon and rarely rectovaginal septum and posterior fornix. Extrapelvic endometriosis is a rare disease typically located in the proximal bowel segments (jejunum/ileum/appendix), abdominal wall including umbilicus, scars after spontaneus delivery and/or after cesarian section, lungs and diaphragm.

CONCLUSION

Ultrasound diagnosis of pelvic DE has a high accuracy in the hands of an experienced sonographer. Extrapelvic endometriosis is sporadic and imaging of choice depends on the location, such as use of magnetic resonance in retroperitoneal disease (sciatic nerve), computed tomography or endoscopy in thoracic lesions.

Diagnosis of endometriosis 1st part - Overview of diagnostic approaches

Cíl studie: Shrnutí současných poznatků a trendů v oblasti diagnostiky endometriózy. Typ studie: Literární přehled. Název a sídlo pracoviště: Centrum pro komplexní léčbu endometriózy a Onkogynekologické centrum, Gynekologicko-porodnická klinika, 1. lékařská fakulta, Univerzita Karlova a Všeobecná fakultní nemocnice Praha; Department of Gynaecology and Obstetrics, Burton Hospitals NHS, UK. Metodika: Systematický přehledový článek. Výsledky: Diagnóza endometriózy v primární péči je stanovena na podkladě anamnézy, fyzikálního vyšetření a základního ultrazvukového vyšetření, které zobrazí přítomnost endometroidních cyst, adenomyózy a nepřímé známky srůstů. Použití krevních či močových biomarkerů se nedoporučuje. Pacientky s podezřením na přítomnost endometriózy by měly být odeslány do specializovaného centra léčby endometriózy, kde jsou k dispozici zkušení sonografisté anebo radiologové v rámci expertního ultrazvuku anebo magnetické rezonance a specializovaný chirurgický tým. Vysoká diagnostická přesnost obou zobrazovacích metod nepodporuje rutinní využití laparoskopie v diagnostice endometriózy, může však být zvažována k vyloučení povrchové anebo extrapelvické endometriózy u symptomatických pacientek s negativním nálezem při zobrazovacích metodách. Závěr: Během základního ultrazvukového vyšetření by ošetřující gynekolog měl být schopen zobrazit přítomnost endometroidních cyst, adenomyózy a nepřímé známky adhezí a na základě ultrazvukového nálezu anebo typických symptomů odeslat pacientku do centra pro léčbu endometriózy. Expertní ultrazvukové vyšetření pánevní endometriózy je obvykle dostupné ve specia-lizovaných centrech léčby endometriózy. Vzhledem k vysoké diagnostické přesnosti ultrazvuku, jeho běžné dostupnosti v gynekologii, nižší ceně a absenci kontraindikací ve srovnání s magnetickou rezonancí je ultrazvuk metodou volby v zobrazení rozsáhlé pánevní endometriózy, zatímco magnetická rezonance je využívána jako metoda druhé volby v obtížných případech.

Diagnosis of endometriosis 2nd part - Ultrasound diagnosis of endometriosis (adenomyosis, endometriomas, adhesions) in the community

OBJECTIVE

To summarise the current knowledge and trends in the basic ultrasound diagnosis of adenomyosis, endometroid cysts and pelvic adhesions.

DESIGN

Review article.

SETTING

Centre for diagnostics and treatment of endometriosis and Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Gynaecology and Obstetrics, Burton Hospitals NHS, United Kingdom.

METHODS

Literature review.

RESULTS

Endometriosis is a relatively common disease, which often escapes timely diagnosis, although sonographic features of adenomyosis, endometriomas and pelvic adhesions can be easily assessed on the basic ultrasound examination. Endometriomas are ovarian cysts in a premenopausal patient with ground glass echogenicity of the cyst fluid, one to four locules and no papilary projections with detectable blood flow. Adenomyosis is characterised by an asymmetrical thickening of the myometrium due to an ill-defined myometrial lesion with fan-shaped shadowing, non-uniform echogenicity with myometrial cysts, hyperechogenic islands, hyperechogenic subendometrial lines and buds with an irregular or interrupted junctional zone, and translesional vascularity containing vessels crossing the leasion perpendicular to the endometrium. Pelvic adhesions can be detected using dynamic aspect of ultrasound examination demonstrating negative sliding sign of the uterus and/or ovaries against surrounding tissue planes and site-specific tenderness. Distorted pelvic anatomy (the presence of uterine ‚question mark sign and/or ‚kissing ovaries) is another sign of adhesions.

CONCLUSION

First step in basic transvaginal ultrasound is visualisation of the uterus and ovaries, assessment of their mobility and tenderness during examination. Knowledge of the characteristic ultrasound features of adenomyosis, endometriomas and adhesions enables timely diagnosis of endometriosis by the community gynecologist and prompt referral to the endometriosis centre.

The role of ultrasound in primary workup of cervical cancer staging (ESGO, ESTRO, ESP cervical cancer guidelines)

OBJECTIVE

In 2018 three European societies have joined to create clinically relevant guidelines on the diagnosis and management of cervical cancer. The European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) agreed on diagnostic approaches in cervical cancer staging.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague.

METHODS

A literature review of published data on cervical cancer staging.

RESULTS

Physical examination with biopsy still has its place in histological confirmation of malignancy but doesnt offer much information on the extent of the disease. It is historically the first time when transvaginal/transrectal ultrasound (TVS/TRS) is recommended as an alternative to the magnetic resonance (MRI) in a primary workup. Both imaging modalities offer excellent soft tissue contrast resolution, which is crucial in tumour detection and evaluation of local extent of tumour, including the depth of tumour infiltration in the bladder and rectal wall. These new advances in imaging rendered the use of cystoscopy and rectoscopy redundant. Similarly, with the implementation of modern imaging in pretreatment staging, intravenous urography has lost its role in the staging. Apart from the local extent of the disease, it is necessary to accurately evaluate the lymph node status in order to plan optimal treatment. The detection rate of imaging reflects the prevalence of lymph node metastases depending on tumor stage and size of metastasis. In the early stage disease (T1a, T1b1, T2a1) with negative lymph nodes on TVS/TRS or MRI, surgicopathological staging of pelvic lymph nodes is a method of choice for detection of small volume metastases. Both imaging modalities might not detect small metastatic lesions within non-enlarged lymph nodes, but by identifying the characteristic changes of the infiltrated lymph nodes they have very low rate of false positives. In locally advanced cervical cancer (T1b2 and higher, except T2a1) or early stages with positive lymph nodes detected on ultrasound or MRI, computed tomography (CT) or CT in combination with positron emission tomography (PET-CT) are recommended to assess distant spread including paraaortic lymph nodes and chest. PET-CT is the preferred option in cases indicated for primary chemoradiation. Unfortunatelly no imaging method is accurate enough to exclude small volume metastasis in paraaortic nodes. In the cases with negative paraaortic lymph nodes on CT or PET-CT, surgicopathological staging with dissection of the paraaortic lymph nodes may be considered. In order to reduce false positive findings by imaging methods, it is recomended to obtain an ultrasound or CT-guided tru-cut biopsy from any equivocal extrauterine lesion to avoid inappropriate treatment.

CONCLUSION

This review offers scientific evidence that led to the recent changes in the cervical cancer staging.

[Contribution of sentinel lymph-node biopsy to treatment of locally advanced stages of cervical cancers]

OBJECTIVE

Usage of sentinel lymph-node (SLN) concept in locally advanced cervical cancers might help to individualise management. According to SLN status could be patients refered to neoadjuvant chemotherapy (NAC) with subsequent surgery or to primary chemoradiation. The aim of our study was to evaluate sensitivity of SLN detection in locally advanced cervical cancers and to assess the impact of NAC on frequency of their metastatic involvement.

DESIGN

Retrospective clinical study.

SETTING

Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague.

MATERIALS AND METHODS

Included were patients with cervical cancer stages FIGO IB1 (> 3 cm), IB2, IIA2 and selected cases of stages IIB with incipient parametrial involvement. Patients were distributed into two different protocols - patients in group NAC-SLN were refered to radical hysterectomy with SLN biopsy after 3 cycles of NAC, other patients (group SLN) underwent SLN biopsy and NAC was administered only in SLN-negative cases.

RESULTS

Altogether 101 patients were included (group SLN = 62, group NAC-SLN = 39). Detection of SLN in whole cohort reached 90.1% per patient and 68.3% bilaterally. No differences were found between SLN group and NAC-SLN group in frequency of per patient SLN detection (90.3% vs 89.7%) and bilateral detection (69.4% vs 66.7%). Prevalence of macrometastases, micrometastases and ITC in the SLN group was 37.1% (23/62), 11.3% (7/62) and 8.1% (5/62), respectively. In the NAC-SLN group macrometastases in SLN were detected in 17.9% (7/39) patients, in 1 patient was detected micrometastis in SLN and no patient had ITC. Difference in frequency of metastases in SLN was significant (p = 0,013). No patient had progressed during NAC, complete response was seen in 15.1% (11/73) patients and reduction of tumour volume > 30% in 84.9% (62/73) patients.

CONCLUSIONS

Detection of SLN in locally advanced cervical cancers reached comparable results to early stages. NAC did not influence frequency of SLN detection, but it significantly decreased prevalence of metastatic SLN involvement.

[Recommended guidelines of diagnosis for women with an ovarian cyst or tumour]

Transvaginal ultrasonography is the first-line and best imaging technique for characterising adnexal masses preoperatively. The optimal approach is the subjective assessment of ultrasound images by experts. An alternative evidence-based approach to the pre-surgical diagnosis of adnexal tumours is to use simple ultrasound rules or logistic regression model LR2 developed by the International Ovarian Tumor Analysis (IOTA) group. Their test performance matches subjective assessment by experienced examiners and should be adopted as the principal test to characterize masses as benign or malignant. Measurements of serum CA 125 are not necessary for characterization of ovarian pathology in premenopausal women and are unlikely to improve the performance of experienced ultrasound examiners, even in the postmenopausal group. However, in postmenopausal patients, serum CA 125 may play a role as a second-stage test, especially in centers with less-experienced ultrasound examiners.

[Ultrasound staging of endometrial cancer - recommended methodology of examination]

The extent of the staging surgery in cases of histologically proven endometrial cancer depends on whether the tumor is of high risk or low risk for extrauterine spread and recurrence. There are several significant prognostic factors - histological subtype and grade of dediferentiation from preoperative biopsy and local stage of uterine involvement based on imaging methods. The depth of myometrial invasion and presence of cervical stromal infiltration (local staging) can be assessed by ultrasound with the overall accuracy comparable to that of magnetic resonance. Transvaginal ultrasound enables to vizualize detailed pelvic anatomy and that is why it is considered to be a suitable tool for assessment of local stage of endometrial cancer. It is advisable to use the standardized terminology defined by International Endometrial Tumor Analysis group (IETA) to describe ultrasound findings. The standardized methodology of ultrasound preoperative staging examination based on prearranged protocols is recommended.

[The optimal imaging in gynecological oncology]

In this review we discuss in detail the advantages and the limitations of the modern imaging techniques to assess the tumour spread in pelvis, abdomen and extraabdominally in patients with newly diagnosed or recurrent gynecological cancer. Transvaginal ultrasound and magnetic resonance imaging yield similar levels of accuracy when utilised for the diagnosis of gynecological cancer and the detection of pelvic spread. Ultrasound is, however, a commonly available, non-invasive, and inexpensive imaging method that can be carried out without any risk or discomfort to the patient. Although increasing evidence shows that transabdominal ultrasound is an accurate technique for the detection of intra- and retroperitoneal tumour spread, it requires experience, adequate equipment and suitable acoustic conditions. Contrast-enhanced computed abdominopelvic tomography remains the most commonly used preoperative imaging modality to assess abdominal cavity and retroperitoneum for extrapelvic tumour spread. Alternatively magnetic resonance imaging can be used in cases of contra-indication of computed tomography. If there is suspicion of extraabdominal tumour spread, contrast-enhanced computed tomography of thorax or positron emission tomography combined with computed tomography is used. Positron emission tomography combined with computed tomography detects more distant metastases than computed tomography alone. Positron emission tomography with computed tomography is, therefore, the optimal imaging technique for suspected recurrence, particularly if there is suspicion of recurrence but conventional imaging methods have yilded negative results or if salvage surgery is planned.

[Ultrasonic staging cervical cancer -a proposal for the standard procedure]

OBJECTIVE

To develop guidelines for the ultrasound examination of cervical cancer, including a unified ultrasound terminology.

SUBJECT

Original paper.

SETTING

Gynecological Oncology Center, Department of Obstetrics and Gynecology, Masaryk University and General Faculty Hospital Brno, and Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University in Prague - First Faculty of Medicine and General Faculty Hospital Prague.

SUBJECT AND METHOD

The standard diagnostic algo-rithm for examination of cervical cancer in oncogynecology centers in the Czech Republic is based on published studies, own experience (Oncogynecological Center, Department of Gynecology and Obstetrics,1st Medical Faculty, Charles University) and the experiences of a group of ultrasonographers involved in the grant project IGA MZ ČR NT13070 focused on the implementation of an oncogynecological ultrasound into clinical practice. Standard ultrasound examination includes two-dimensional real-time ultrasound examination (sagittal and transverse views). Transrectal or transvaginal ultrasound examination is combined with transabdominal ultrasound. Prerequisites are quality ultrasound equipment, a high frequency microconvex linear probe and abdominal convex and linear probe. The examination is performed by an experienced sonographer (level 2 or 3 according to the recommendations of the Ultrasound division of the Czech Society of Obstetrics and Gynecology and the Czech Society of Ultrasound in Obstetrics and Gynecology). Intravenous administration of contrast material or three-dimensional ultrasound examination do not influence accuracy of the examination and is not a prerequisite.

CONCLUSION

Based on the consensus of experienced sonographers and a review of the literature, guidelines were created for ultrasound staging of cervical cancer.

[Cervical cancer staging - preoperative assessment of tumor extent (a review of the most recent ultrasound studies)]

For treatment planning of cervical cancer it is necessary preoperatively to determine the presence and size of residual tumour after the biopsy, the tumour topography within the cervix and the parametrial and lymph node status. According to current data, ultrasound is comparably accurate with magnetic resonance imaging in view of tumour presence and local extent assessment. Ultrasound, if compared with the magnetic resonance imaging, does not have known contraindications and it is a broadly available diagnostic test. Currently no advanced imaging technique exists that can reliably detect infiltrated lymph nodes in the clinically early stage of the disease, as it often manifests as micrometastatic involvement in non-enlarged lymph nodes. The sensitivity of lymph node detection using ultrasound in the early stage is around 40%, but the specificity is high (96%). For daily practice, this means that a negative ultrasound finding should be always verified by surgical staging based on systematic lymphadenectomy, while positive ultrasound finding usually changes the treatment strategy.

[Endometrial cancer - preoperative identification of low and high risk endometrial cancer (a review of the most recent ultrasound studies)]

Despite the high resolution of ultrasound or magnetic resonance imaging and modern bioptic approaches, diagnostic error of preoperative staging is around 20%. The preoperative staging is focused to differentiate low risk (< 50% myometrial invasion, histological grade 1 and 2, endometrioid cancer, no cervical invasion) or high risk endometrial cancer (all others). Preoperative biopsy tends to underestimate the tumour histotype and grading in 20% of cases. Therefore, the sonomorphological and Doppler pattern have been identified that can preoperatively alert us to the presence of low or high risk endometrial cancer. With discrepancy between preoperative ultrasound tumour characteristics and results of endometrial biopsy a supplementary intraoperative frozen section of uterus is recommended. Ultrasound examination performed by an experienced sonographer is accurate in most cases but tends to overestimate myometrial invasion and underestimate cervical stromal invasion. Based on the identification of factors that significantly affected the accuracy of ultrasound, it was recommended to restrict evaluation to sonomorphological tumour parameters within the preoperative tumour staging. This is in response to the tendency of ultrasound experts with knowledge of the clinical data of patients, and prognostic parameters of the disease who have encountered adverse tumour characteristics through ultrasound (e.g. inhomogeneous, hypo- or isoechogenous tumor with high tumour perfusion) to 'intuitively overestimate the stage of the disease and conversely. The attempts to restrict the assessment of tumour invasion to those parameters that are easily and objectively evaluated has not so far proved effective. A promising objective parameter seems to be the minimum distance between the tumour and uterine serosa. When this parameter was included in the new objective model, the high-risk endometrial cancer was predicted with an accuracy similar to subjective assessment of tumour invasion by an expert. The preoperative work-up for high-risk endometrial cancer prediction was designed and externally validated in order to triage the patients for adequate staging surgery. This approach was based on the combination of the results of preoperative endometrial biopsy and transvaginal ultrasound and reached the similar accuracy as a more complicated approach using a combination of magnetic resonance imaging and hysteroscopic-directed biopsies. Both approaches can identify eight of 10 women with high-risk of lymph node metastases and spare eight of 10 low-risk women extended surgery.

[Diagnostic algorithm in pregnancies of uncertain viability or unknown location - a review of the latest recommendations]

Based on current knowledge the criteria for diagnosing nonviability in early intrauterine pregnancy and diagnostic algorithm in pregnancies of unknown location have changed. For either an intrauterine pregnancy of uncertain viability or a pregnancy of unknown location, the consequences of false positive diagnosis of nonviability or false negative diagnosis of ectopic pregnancy may be dire: harming of a potentially normal intrauterine pregnancy or a life-threatening rupture from tubal pregnancy. This review aims to present the most important results of current studies on this topic with their recommendations and to improve patient care reducing the risk of inadvertent harm to potentially normal pregnancies.

[The rational preoperative diagnosis of ovarian tumors - imaging techniques and tumor biomarkers (review)]

The majority of patients who suffer from an early-stage or advanced-stage of ovarian cancer complain about symptoms, mainly gastrointestinal ones. The pelvic examination in ovarian cancer detection is limited by the adnexal position in the pelvis and frequent extraovarian spread of disease. Recently, any reliable tumor biomarker (CA 125 and/or HE4), which can be used in differential diagnosis between benign and malignant ovarian tumors, does not exist. According the results of the largest multicenter International Ovarian Trial Analysis (IOTA), ultrasound if performed by an experienced sonologist is an ideal diagnostic method in differential diagnosis between benign and malignant ovarian tumors. The experienced examiner is also able to detect extraovarian tumor spread and to assess tumor operability. Magnetic resonance imaging (MRI) is used only to complement ultrasound in cases when high tissue resolution is needed. Computed tomography (CT) is a useful method for detection of extraovarian spread, especially in cases when an ultrasound examiner experienced in abdominal scanning is not available. Similarly, fusion of positron emission tomography with CT (PET/CT) is a highly accurate method for the detection of abdominal and extraabdominal tumor spread, but its use is limited by cost and the low availability of this method. On the other hand, PET/CT is not recommended for primary ovarian cancer detection because of its lower sensitivity in comparison to ultrasound and its high false positive rates as well.

Myxoid mixed low-grade endometrial stromal sarcoma and smooth muscle tumor of the uterus. Case report

We report the case of a 73-year-old female with myxoid mixed low-grade endometrial stromal sarcoma and smooth muscle tumor of the uterus. Grossly, the tumor sized 130 x 130 x 100 mm involved the uterine corpus almost in its entirety. Histologically, the tumor consisted of two cell types. In some areas, the tumor cells showed typical features of endometrial stromal tumors and resembled stromal cells of proliferative endometrium. In other areas, however, the tumor showed smooth muscle features and consisted of larger mostly epitheloid cells with a moderate amount of cytoplasm. In all areas, myxoid changes and multiple hyalinizing giant rosettes were present. The tumor infiltrated the myometrium in a pattern typical of low-grade endometrial stromal sarcoma. Immunohistochemically, the tumor cells showed expression of vimentin, estrogen and progesterone receptors and variable expression of CD10, α-smooth muscle actin, desmin, h-caldesmon, and cytokeratin AE1/AE3. Other markers examined including CD99, α-inhibin, cytokeratin CAM5.2, S-100 protein, and HMB45 were negative. To the best of our knowledge, mixed low-grade endometrial stromal and smooth muscle tumor with myxoid changes has not been described to date.

[Transabdominal ultrasound examination in gynecology]

OBJECTIVE

To present structured guidelines to transabdominal ultrasound examination in gynecology.

SUBJECT

Practical guide.

SETTING

Oncogynecological Center, Department of Obstetrics and Gynecology, Charles University in Prague - First Faculty of Medicine and General Faculty Hospital, Prague.

SUBJECT AND METHOD

After having gone over the now-a-days literature and summarized our experience, we present description of normal and more frequent and common pathological findings on transabdominal ultrasound.

CONCLUSION

Entire examination takes usually a couple of minutes, but gives much more information to distinguish between potential causes of patient's difficulties and allows for focusing an adequate diagnostic and therapeutic management.

[Ultrasound-guided minimally invasive interventions in gynecologic oncology]

OBJECTIVE

To present our experience with ultrasound-guided minimally invasive interventions in gynecologic oncology.

SUBJECT

Original paper.

SETTING

Oncogynecological Center, Department of Obstetrics and Gynecology, Charles University in Prague - First Faculty of Medicine and General Faculty Hospital, Prague.

SUBJECT AND METHOD

We provide minimally invasive punction interventions under ultrasound guidance using either abdominal or vaginal probe in three indication groups - diagnostics (tru-cut biopsy), therapy (punction drainage of lymphocyst) and palliation (insertion of permanent peritoneal catheter).

CONCLUSION

Ultrasound-guided minimally invasive interventions represent a group of accessible and relatively simple methods useful in many indications, not only in gynecologic oncology. Adoption of these methods allows to broadening the spectrum of interventions offered and decreasing patient's stress.

[Hereditary susceptibility to endometrial cancer]

OBJECTIVE

To present up-to-date knowledge concerning field of hereditary susceptibility to endometrial cancer as a part of hereditary non-polyposis colorectal cancer (Lynch syndrome).

SUBJECT

Review.

SETTING

Oncogynecological Center, Department of Obstetrics and Gynecology, Charles University in Prague, First Faculty of Medicine and General Faculty Hospital, Prague.

SUBJECT AND METHOD

After having gone over the now-a-days literature and summarized our experience with management of high risk women of Lynch syndrome families we present up-to-date overview of this field problematics.

CONCLUSION

Although endometrial cancer arising due to germ-line susceptibility account for a small part of these malignancies only, they represent disease with clearly defined and detectable serious risk factor. Management approach for these women is now defined and allows for early detection or lowering the risk. Educated gynecologist, as a field specialist, has good chance to identify women at risk and manage them in an appropriate way.

[Molecular characterization of epithelial ovarian borderline tumors with respect to clinical management and prognosis]

OBJECTIVE

To analyze up-to-data knowledge in the field of molecular characterization of epithelial ovarian borderline tumors with respect to clinical management and prognosis.

DESIGN

Review.

SETTING

Oncogynecological Center, Department of Obstetrics and Gynecology, Charles University in Prague, First Faculty of Medicine, and General Faculty Hospital, Prague.

METHODS

Based on literature search and own experimental data in the field of molecular biology of ovarian cancer and borderline tumors of ovary, we summarize up-to-date knowledge of molecular differences and specific features of BTO with respect to implementation of these knowledge into the clinical management.

RESULTS AND CONCLUSION

We suppose that spectrum of genomic changes (i.e. genetic and epigenetic) causing tumor transformation is limited and these changes take place in stem or progenitor cell. Analysis of genomic changes can help to define certain subtypes of BTO and, correlated to clinical characteristics, to identify subtypes with different biological behavior. Such molecular typing of BTO allows to individualize treatment.

[Ultrasound-guided intervention in the treatment of abdomino-pelvic advanced tumors]

OBJECTIVE

The goal of this study was to evaluate the accuracy and safety of ultrasound-guided tru-cut biopsy in advanced abdomino-pelvic tumors in a sufficiently large cohort.

DESIGN

Prospective study.

SETTING

Oncogynecological Center, Department of Obstetrics and Gynecology, General Faculty Hospital of Charles University, Prague.

METHODS

Patients indicated for tru-cut biopsy were those with primarily inoperable tumors, with advanced tumors and compromised performance status preventing a primary surgical procedure, and with recurrent pelvic tumors requiring histological verification. All were referred to the Oncogynecological Center between January 2005 and June 2007. Tru-cut biopsy was taken either from pelvic tumor or from its metastatic sites transvaginally or transabdominally under ultrasound guidance. Sample adequacy was evaluated.

RESULTS

Altogether, 119 patients were referred for tru-cut biopsy during a study period. Only 4 cases were found unsuitable for tru-cut biopsy and the patients were referred for laparoscopy instead. Samples were obtained transvaginally in 67 patients (58.3%) and transabdominally in 48 patients (41.7%). The biopsy was taken from pelvic tumor in 59 patients (51.3%), omental cake in 14 patients (12.2%), from peritoneal visceral or parietal carcinomatosis in 37 patients (32.2%) and from other localities in 5 patients (4.3 %). The diagnostic adequacy of ultrasound-guided tru-cut biopsy reached 94.8% (95% CI, 94.17-99.40%). There were only two tru-cut biopsy-related complications: The first case involved bleeding from tumor in a patient with mild thrombocytopenia that required laparotomy; in the second case, diagnostic laparoscopy was indicated after a minor bleeding occurred in the biopsy site on ultrasound, however, no significant pelvic bleeding was confirmed by the procedure.

CONCLUSION

Ultrasound-guided tru-cut biopsy is a safe, reliable, fast, and cost-effective diagnostic method for histological verification of both advanced primary and recurrent abdomino-pelvic tumors. It can be performed in an outpatient setting without the need for general anesthesia, causing a minimal discomfort to the patient in comparison with laparoscopy or laparotomy. The risk of complications is low and the main advantage is the acquirement of a sample adequate for further immunohistochemical examination, which is a necessary requirement for the choice of optimal oncological treatment.

[Use of transrectal ultrasound and magnetic resonance imaging in the staging of early-stage cervical cancer]

OBJECTIVE

The goal of this study was to compare the accuracy of magnetic resonance imaging (MRI)--a standard method--and transrectal ultrasound (TRUS) in the staging and determination of significant prognostic parameters in early-stage cervical cancer. The following prognostic parameters were evaluated: identification of residual tumor in the cervix after cone-biopsy, tumor volume, and early parametrial infiltration.

DESIGN

Prospective study.

SETTING

Oncogynecological Center, Department of Obstetrics and Gynecology, General Faculty Hospital of Charles University, Prague.

METHODS

Patients referred to Oncogynecological Center from January 2004 to February 2006, in whom early-stage cervical cancer (T1a1-T2a) was diagnosed by clinical examination, were prospectivelly enrolled in the study. Only those patients who were examined by both MRI and TRUS with following surgical treatment were included. Imaging results were compared with pathology findings.

RESULTS

Data from 95 patients were evaluated. The accuracy of tumor detection in 95 patients was 93.7% for TRUS and 83.2% for MRI (P < or = 0.006). In small tumors (< or = 1 cm3), the accuracy of tumor detection by TRUS was 90.5% and 81.1% by MRI (P < or = 0.049). The accuracy of parametrial infiltration detection by TRUS and MRI was 98.9% and 94.7%, respectively (P < or = 0.219). The accuracy was not influenced by body mass index values.

CONCLUSION

Our results show TRUS achieving comparable or even higher accuracy than the more commonly used MRI in staging of early-stage cervical cancer.

[Inactivation of BRCA1, BRCA2 and p53 genes in sporadic ovarian cancer]

OBJECTIVE

To analyze loss of heterozygosity (LOH), loss of expression and somatic mutations of BRCA1, BRCA2 and p53 genes in sporadic epithelial ovarian cancer samples.

DESIGN

Original paper.

SETTING

Oncogynecologic center, Clinic of Obstetrics and gynecology, First Faculty of Medicine, Charles University in Prague and General Teaching Hospital, Prague.

MATERIAL AND METHODS

We used genomic DNA and total RNA from peripheral blood and fresh frozen tumor as a template for LOH, loss-of-expression and mutation analyses.

RESULTS

LOH in at least one region was found in 60% of tumors. Majority of these alterations occurred not solely, but in conjunction with other region deletions.

CONCLUSION

Our study confirms high frequency of somatic alteration of BRCA1, BRCA2 and p53 genes in sporadic epithelial ovarian cancer.

[Detection of HPV DNA in lymph nodes in early stages cervical cancers]

OBJECTIVE

Review recent knowledge concerning significance of detection of DNA HPV in regional lymph nodes in cervical cancer patients.

TYPE OF THE STUDY

Literature review.

SETTING

Department of Obstetrics and Gyneacology, 1st Faculty of Medicine, Charles University and General Teaching Hospital, Prague.

RESULTS

Metastatic involvement of pelvic lymph nodes is the most important prognostic parameter in early stages cervical cancer. Still, almost 20% of patients with negative pelvic nodes experience recurrence. Detection of HPV DNA in lymph nodes might be a marker of occult metastatic involvement. However, published data are limited, mostly due to inconsistent methodology. Only 3 prospective studies evaluating HPV from fresh or frozen tissue were published till now, all other retrospective studies extracted HPV DNA from paraffin embedded samples. A few papers showed correlation between HPV DNA and metastatic involvement of pelvic lymph nodes. DNA HPV identification in histopatology-negative nodes was considered as a risk factor for recurrence. Presence of DNA HPV 18 in histopathology-negative pelvic nodes was described as a poor prognostic factor; however prognostic significance of individual genotype is still unclear.

CONCLUSION

Detection of high risk HPV DNA in regional lymph nodes is a good candidate for prognostic parameter in early stages cervical cancers. The group of women with both absence of metastatic involvement and negative HPV DNA evaluation of regional lymph node should represent a cohort of patients with particularly good prognosis.

[Ductal approaches in mammary diagnostics]

OBJECTIVE

Information about new possibilities of early diagnostics in mammary lesions.

TYPE OF STUDY

Review.

SETTING

Gynecology-Obstetrics Clinic, 1st Medical Faculty and General Teaching Hospital, Prague.

SUBJECT AND METHODS

Most malignant tumors of the breast originate from ductal epithelium. A direct examination of the ductal system, could significantly improve diagnostics of breast cancer as well as its preinvasive stages (DCIS) and to influence mortality. The concept of ductal approaches includes several techniques and ductal lavage and duscoscopy.

CONCLUSIONS

Ductal approaches represent an attractive area for minimal load upon the patients. Specificity and sensitivity of these methods have some limits, which will be subject to change in relation to understanding of carcinogenesis and in a close relation to the knowledge of biomarkers, genomics and proteomics. Ductoscopy appears to be the ideal method for the future due to possibilities of direct visualization of epithelium in combination with biopsy and ductal lavage. It other advantages include minimal invasiveness, minimal risk and the origin of possible complications for the patient.

[Contribution of neoadjuvant chemotherapy for operability of cancers of the uterine cervix]

OBJECTIVE

To compare per-operative and post-operative morbidity in patients undergoing radical surgery for carcinoma of the uterine cervix after administration of a neoadjuvant chemotherapy, and for primarily small cervical tumour.

TYPE OF THE STUDY

A retrospective case-control study.

SETTING

Department of Obstetrics and Gyneacology, 1st Faculty of Medicine, Charles University and General Teaching Hospital, Prague.

METHODS

The study included 24 patients with squamous cell carcinoma of the uterine cervix who underwent radical hysterectomy including systematic pelvic lymphadenectomy after previous administration of neoadjuvant chemotherapy (NACT) during the period between 1/2004 and 6/2006. The control group of 24 patients was selected retrospectively from the population of women after radical surgery carried out in the same period, nevertheless, the controls underwent the surgery for primarily small carcinoma of the uterine cervix, stages IA2 or IB1. The tumour size consistent with the reduced tumour after NACT administration was the criterion for selection of the control group. The following parameters were monitored in both groups--duration of the surgery, blood loss objectivised by a difference in pre-operative and post-operative haemoglobin and haematocrit values, the need of blood transfusion, per-operative complications, early post-operative complications (up to 6 weeks after the surgery), duration of hospitalization and retaining the inserted epicystotostomy due to hypotonic bladder after discharge.

RESULTS

A therapeutic response allowing the radical surgery was achieved in 92% patients after NACT. After NACT the original tumour volume was reduced by 70% on the average (58% - 100%). No significant differences between the group of patients treated with NACT and undergoing subsequent radical hysterectomy and the control group were reported in terms of duration of the surgery (165 min. vs. 160 min.), blood loss (the difference in pre-operative and post-operative haemoglobin values 18 g/l vs. 19 g/l, the difference in pre-operative and post-operative haematocrit values 0.056 vs. 0.064), administration of blood transfusion (25% vs. 21%) and duration of hospitalization (9.5 days vs. 9.6 days). A significant difference was reported only in the need to retain the inserted epi-cystostomy after discharge (67% vs. 47%).

CONCLUSION

There were no significant differences in the evaluated parameters of per-operative and postoperative morbidity in patients after NACT and in control patients, except for the necessary duration of artificial urine derivation in patients after NACT due to the fact that their surgery was more radical in the parametria. Administration of NACT regimen involving ifosfamide/cisplatin (IP) improved surgical conditions in the bulky squamous cell carcinoma of the uterine cervix.

[Glandular premalignant lesions of the uterine cervix]

OBJECTIVE

Review of diagnostical and therapeutical methods in glandular premalignant lesions of the uterine cervix.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gyneacology, 1st Medical Faculty, Charles University and General Faculty Hospital, Prague.

RESULTS

The incidence of invasive adenocarcinomas of the uterine cervix is increasing. Incidence ratio between adenocarcinomas and spinocellular carcinomas is approximately 1:5; however ratio of premalignant lesions reaches only about 1:80. Glandular premalignant disease is usually found in the specimen taken for squamous disease. The coincidence of both types of premalignant lesions, so called "mixed lesion", is revealed in about 46-72%. PAP-smear of AGC-NOS/-NEO or adenocarcinoma in situ (AIS) in combination with typical colposcopic appearance raise a suspicion of glandular lesion. Direct biopsy must be always performed to get definite diagnosis. Optimum biopsy technique requires cylindrical excision. A woman can be carefully followed if desires pregnancy and specimen margins are negative. Hysterectomy is indicated if reproductive plans are completed.

CONCLUSION

Diagnosis of glandular premalignat lesion of the uterine cervix is more complicated in comparison to spinocellular one, however it is getting more significant due to increasing incidence. Colposcopy and cytology are less reliable. Any suspicion on glandular premalignat leasion requires more active approach and radical procedure (hysterectomy) if possible.

[Radical parametrectomy in women with invasive cervix cancer after previous simple hysterectomy]

OBJECTIVE

Evaluate technique, indications and limits of surgical procedure in the treatment of cervical cancer diagnosed from uterus specimen from simple hysterectomy.

DESIGN

Retrospective observational study, review of literature.

SETTINGS

Department of Obstetrics and Gynecology, 1st Medical Faculty and General Faculty Hospital, Charles University, Prague, Czech Republic.

METHODS

Women following radical parametrectomy with upper vaginectomy and pelvic lymphadenectomy were enrolled to the study. In all patients unexpected invasive cervical cancer was found from the uterus specimen after simple hysterectomy.

RESULTS

Together 10 patients were enrolled to the study. CIN was the indication for primary hysterectomy in all but two patients. There were two operative complications, cystostomy in both cases, treated properly during surgery. In the specimen from radical procedure residual tumor in parametria was found in 2 cases, and metastasis to pelvic nodes in 4 cases. There was no postoperative complication. Adjuvant radiotherapy was recommended in 4 patients due to positive lymph nodes, in one case due to residual tumor in parametria, and in one case for both reasons.

CONCLUSIONS

Radical parametrectomy with upper vaginectomy and pelvic lymphadenectomy should be considered as an alternative solution in patients following simple hysterectomy with unexpected finding of invasive cervical cancer. Morbidity of the procedure is higher in comparison to standard radical hysterectomy, however majority of complications are easy to repair. The most significant criteria for patient's selection for surgical approach is a depth of invasion to cervical stroma. In our group radical procedure obviated the need for radiotherapy in half of the patients.

[Reconstruction procedures following pelvic exenterations]

OBJECTIVE

Review of reconstruction procedures following pelvic exenterations.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, Department of Urology, 1st Department of Surgery, Faculty Teaching Hospital and 1st Medical Faculty of the Charles University, Prague.

METHODS

Review and critical assessment of published data.

CONCLUSIONS

Reconstruction procedures are important part of pelvic exenterations. The procedures are crucial for following quality of life. Currently the most frequently used techniques for isolated pelvic floor support are omental flaps (carpets), for combined reconstruction of pelvic floor and vagina TRAM (transverse rectus abdominis musculocutaneus flap). Reconstructions prolong operation time; however they are accompanied with low morbidity and some techniques decrease total morbidity of exenterative procedure. Total and posterior exenterations require sigmoideostomy in vast majority of cases. Low rectal anastomosis might be used in cases of supralevator procedures. They cause high morbidity especially in patients following radiotherapy. In these patients temporary diverting colostomy is being recommended. A bowel segment is usually used for urinary diversion following total or anterior exenteration. Golden standard remain the incontinent ureteroenterostomies using ileum or colon transversum. Currently continent diversions are considered more often due to encouraging results and good quality of life. Heterotopic diversions, with continent conduit and cutaneous stoma, are frequently used. Risk of serious complications, especially fistulas and stoma stenosis, after all types of diversions is possible to reduce by using appropriate bowel segment not handicapped by previous radiotherapy.

[Possibilities of increased radicality in pelvic exenteration]

OBJECTIVE

Review of advanced radicality in pelvic exenterations.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, General Faculty Hospital and Ist Medical Faculty of the Charles University, Prague.

METHODS

Review and critical assessment of published data.

CONCLUSIONS

More extensive radicality in pelvic exenterations make possible to use surgical treatment in some cases of lateral recurrences or central recurrences with the attachment to the pelvic side wall. One possible technique is a combination of en bloc exenteration with pelvic bone resection, most frequently sacrum. Experiences in gynecological tumours are so far limited. Laterally extended resection was described in lateral infrailiac pelvic wall recurrences. The only one presented paper related to laterally extended procedures showed a reasonable overall survival of patients; however follow-up is limited.

[Borderline ovarian tumors--10-year clinical series and literature review]

OBJECTIVE

Analysis of 10-year clinical series of borderline ovarian tumors (BLT) and literature review.

DESIGN

Retrospective clinical study.

SETTING

Department of Obstetrics and Gynaecology, 1st Medical Faculty, Charles University and General Faculty Hospital, Prague.

METHODS

Analysis of 38 patients from years 1994-2003 regarding age, histological types, tumor duplicities, role of frozen section, Ca125 levels, operation methods, adjuvant treatment, relaps occurrence, follow-up and survival.

RESULTS

Median follow-up was 18.5 months (3-122), median age 51 (16-78).

HISTOLOGY

23 serous, 12 mucinous (1 microinvasion), 2 cystadenofibromas and 1 endosalpingiosis. 26 patients of stage IA, 3 of IB, 6 of IC, 1 of IIA, 1 of IIC and 1 IIIB. 3 cases were underestimated by frozen section. 6 tumor duplicities were revealed. Ca125 marker was elevated in 10/23 (43.5%) cases. 12 patients underwent conservative surgery, 3 of them with complete staging including lymphadenectomy. 26 patients had radical operation, 9 of them with full staging. No one lymphonode was positive. 7 patients had primary laparoscopic approach, 6 had more than one operation. Adjuvant chemotherapy was indicated in 3 cases: PTX-CBDCA (IC and IIC) and CBDCA-CFA (IC). 4 patients were lost of evidence. 2/34 evaluated patients (5.9%) had a frank carcinoma recurrence after 3 and 7 years. Both relapsed patients and all 34 evaluable patients live without evidence of disease at present. Our results as well as literature date generate some controversies. Do we need staging lymphadenectomy in all cases (inclusive T1a)? Which parameters identify high-risk group and which patients will benefit from adjuvant (and which one) therapy? Are there not recurrencies of BLT rather second primary malignancies?

CONCLUSION

In spite of 2 recurrences in a group of 34 evaluated cases all patients live without evidence of disease at present. Some management questions are therefore raised.

[Prophylactic adnexectomy]

OBJECTIVE

Analysis of the issue of prophylactic bilateral salpingo-oophorectomy (BSO): a) during pelvic surgery for benign diagnosis; b) in women with hereditary risk of ovarian cancer.

DESIGN

Review article.

SETTING

Department of Obstetric and Gynecology, Charles University.

METHODS

Critical review of published data.

CONCLUSION

During pelvic surgery for benign diagnosis a prophylactic BSO is indicated of the age over 45, in younger women an individual approach is required, considering many aspects, including history of ovarian and breast cancer. Another indication for BSO is an increased risk of familial ovarian cancer. The surgery significantly diminished the risk of epithelial cancer of ovary, fallopian tube, and simultaneously the risk of breast cancer. There is a continuing increased risk of peritoneal cancer following the surgery. Bilateral oophorectomy together with bilateral salpingectomy is recommended. The age limit for surgery is about 35 years after careful consideration of individual risk, reproductive plans, type of mutation and age at malignant disease manifestation in previous generation. Potential alternative for women who do not accept prophylactic surgery is tubal ligation. Screening of risk group or chemoprevention by oral contraceptives are not equivalent alternatives to prophylactic surgery.