Uterobrush method in the detection of endometrial pathology

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

No significant financial relationships to disclose.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

A two eterochronous primary gynaecological malignancies of different origin

AIM

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

CASE

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

CONCLUSION

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

Primary peritoneal serous papillary carcinoma: clinical and laboratory characteristics

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

CASE REPORT

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

Splenosis of the peritoneal cavity resembling an adnexal tumor: case report

INTRODUCTION

Splenosis is the autoimplantation of ectopic spleen tissue in various anatomic cavities of the body resulting after trauma or rupture of the splenic parenchyma. The major localization sites of this phenomenon are mainly intraperitoneal, the gastrenteric tract, genitalia, intrahepatically and the kidneys. Extraperitoneal locations occur less frequently and include the thorax and brain. Also locallization in the subcutaneous fat has been described.

CASE REPORT

We present the case of a 32-year-old woman with symptomatic peritoneal cavity splenosis occurring ten years after traumatic splenectomy. The patient was admitted to our department with the clinical presentation of an adnexal tumor. US and CT confirmed an adnexal mass. Exploratory laparotomy was performed and multiple focal lesions were noticed on the uterus, ovaries and intestinal tract. Biopsies were taken and sent for histological analysis. The pathology specimen revealed ectopic splenic tissue. After surgical intervention the patient remained asymptomatic.

CONCLUSION

Splenosis is a rare phenomenon which clinicians should be aware of in order to spare patients from pointless surgical interventions. Patients with abdominal masses and post-traumatic splenectomy should be checked for splenosis.

Vaginal carcinoma in a completely prolapsed uterus. A case report

BACKGROUND

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

CASE

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

TREATMENT

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

CONCLUSION

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

Giant solid abdominal mass with cystic lesions: a case report and diaphorodiagnostic approach

A peri-menopausal woman presented with abdominal distention, pelvic discomfort and problems of constipation for the last 4 months. All clinical and radiological examinations were in favor of a giant solid mass with cystic lesions arised from the left ovary. These findings raised suspicion of a primary malignant ovarian tumor or a preudomyxoma peritonei. Surgery revealed a giant mass arised from the uterine fundus. An abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy were preformed. The histological examination verified a degenerated myoma with cystic lesions with no evidence of malignancy. The patient made an uneventful recovery. A gynecologist should always be prepared to perform a different surgery than planned according to operational findings (Fig. 2, Ref. 11).

Preoperative imaging of primary intra-abdominal gynaecological malignancies. Diagnostic accuracy of CT-scan and MRI. A Greek cohort study

OBJECTIVES

To determine the radiological modalities that provide at the initial workout the most accurate information regarding the operability and the type of operation for patients with primary cervical, endometrial, and ovarian carcinomas.

PATIENTS AND METHODS

The medical records of 611 patients with gynaecological cancer were reviewed. The preoperative radiological findings were compared with the intraoperative and pathological ones. The diagnostic accuracy of CT and MRI at various sites was evaluated for all three kinds of carcinoma in combination.

RESULTS

MRI was more accurate than CT in determining cervical enlargement (82% vs 73%), parametrial invasion (91% vs 74%) and the only examination that could evaluate cervical tumour size as well as cervical stromal and myometrial infiltration. Regarding lymph node involvement their results were similar (86% vs 88%). Both methods were comparably accurate in evaluating ovarian tumours (82% vs 84%), ascites (82% vs 81%), omental (73% vs 77%) and mesenterial infiltration (88% vs 93%). They also proved to be highly accurate (100% vs 98%) in the evaluation of solid abdominal organs.

CONCLUSIONS

Non-enchanced MRI should only be used for the preoperative evaluation of a patient with cervical carcinoma, while CT with intravenous and per os contrast media for one with ovarian cancer. Regarding patients with endometrial cancer, no high-resolution method is required for endometrioid grade I tumours, while contrast-enchanced MRI should be employed for all other cases.

Squamous vulvar cancer: a clinically based individualization of treatment

OBJECTIVE

The aim of the study was to evaluate treatment results in 211 patients with previously untreated squamous cell vulvar cancer who were primary managed by surgery at the Gynecologic Oncology Unit of Alexandra Hospital, in terms of en bloc radical vulvectomy (N = 105), modified radical vulvectomy with three different incisions technique (N = 60), and radical hemivulvectomy (N = 46) with inguinofemoral lymphadenectomy.

METHODS

The surgical stage of disease, nodal status, lesion location and focality, marginal status, tumor size, physical and performance status, surgical modality used, and finally complications and recurrence rates were the analyzed factors for both survival and disease remission.

RESULTS

The overall 5-year survival was 70.1%. The 5-year survival for node-positive patients was 53.8% versus 79.7% for node-negative patients. Unifocal lesions had a 5-year survival of 76% compared with 50% of multifocal lesions. Posterolateral lesions had a better 5-year survival than that of anterior central lesions (79.5% vs 54. 4%). The marginal status of the surgical specimen was a significant predictor of both survival and recurrence. There was a significant difference in complications related to the en bloc radical vulvectomy in terms of wound breakdown, infection, and wound cellulitis.

CONCLUSIONS

Modified radical procedures are equally effective with the en bloc radical vulvectomy for the management of early (stage I/II) vulvar cancer. In advanced disease concervative surgery in an individualized approach could also effectively be applied.

A phase II trial of methotrexate, vinblastine, doxorubicin, and cisplatin in the treatment of metastatic carcinoma of the uterine cervix

BACKGROUND

Patients with metastatic carcinoma of the uterine cervix have limited survival. Thus, new chemotherapeutic agents and combinations are needed to improve patient outcome.

METHODS

Twenty-seven patients with Stage IV primary or recurrent carcinoma of the uterine cervix were assigned to chemotherapy treatment at 4-week intervals with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC). The treatment was comprised of methotrexate, 30 mg/m2 administered intravenously (i.v.) on Days 1, 15, and 22; vinblastine, 3 mg/m2 i.v. on Days 2, 15, and 22; doxorubicin, 30 mg/m2 i.v. on Day 2; and cisplatin, 70 mg/m2 i.v. on Day 2. Granulocyte-colony stimulating factor (G-CSF) was given subcutaneously on Days 6-10 at a dose of 5 micrograms/kg.

RESULTS

After a median of 4 cycles (a maximum of 6 in responders), the authors observed objective responses in 14 patients (52%), including 3 complete responses (11%) and 11 partial responses (41%). Median overall survival was 11 months (range, 4-15+ months), and median progression free survival of the responders was 8 months (range, 6-15+ months). Toxicity was acceptable and included neutropenia, alopecia, vomiting, and stomatitis.

CONCLUSIONS

MVAC is an active regimen in the treatment of patients with advanced or recurrent carcinoma of the uterine cervix. It produced responses in one-half of the patients in this study, and it can be administered on an outpatient basis. The addition of G-CSF appears to reduce hematologic toxicity.

Ifosfamide and paclitaxel salvage chemotherapy for advanced epithelial ovarian cancer

OBJECTIVE

To evaluate the efficacy and toxicity of the combination of ifosfamide (1.5 g/m2 i.v. on days 1, 2, 3) and paclitaxel (135 mg/m2 i.v. over 3 hours on day 3) with G-CSF (5 micrograms/kg/d subcutaneously, days 7-11) administered every 3 weeks on an outpatient basis in patients with advanced epithelial ovarian cancer previously treated with platinum-based chemotherapy.

PATIENTS AND METHODS

Thirty-five consecutive patients were treated, 12 of whom had previously received two regimens. Twelve of the 35 were defined as platinum-resistant and 23 as potentially platinum-sensitive.

RESULTS

Fifteen patients (43%; 95% CI: 26%-61%) achieved objective responses, five of them complete and ten partial. Objective responses occurred in 17% of the platinum-resistant patients and in 57% of those with potentially platinum-sensitive disease. The median duration of response was seven months and the median overall survival 11 months. The treatment was well tolerated and only 15% of the patients developed grade 3 or 4 neutropenia. With the exception of alopecia there were no other grade 3 or 4 toxicities.

CONCLUSIONS

The combination of ifosfamide and paclitaxel was well tolerated and showed activity in patients with ovarian cancer who had previously undergone platinum-based chemotherapy.

Comparative study of RIS with the 131I-OC 125 F(ab')2 Mab and CT scan prior to second look operation for ovarian cancer

A tumour-associated radiolabelled monoclonal antibody (Mab) 131I-OC 125 F(ab')2 was used to investigate 27 patients 2 weeks after their last chemotherapy regimen and prior to second-look surgery for ovarian cancer. We did compare the radioimmunoscintigraphy (RIS) findings with the CT scan results and the second-look operation data. In 23 out of 27 cases the RIS results correlated with the operation findings, while there were four false-negative results. Computed tomography (CT) scans correlated in 17 out of 23 cases with the operative findings, while there were six false-negative results. We concluded that RIS is more specific in detecting the tumour site within the pelvis, while CT scan is superior in detecting liver metastases.