Sarcomatous Nodules Associated with Mucinous Neoplasms of Ovary: A Report of Two Cases.

Ovarian mucinous neoplasms (benign/borderline/malignant), one of the common surface epithelial tumours of ovary, at times can be associated with mural nodules. These mural nodules can either be sarcomatous, sarcoma like or anaplastic carcinomatous. The nodules can be single or multiple and appear solid, white to brown in color. Sarcomatous nodules tend to occur in older patients and microscopically are poorly circumscribed, comprising of a population of pleomorphic spindled cells. Two cases of sarcomatous nodules associated with ovarian mucinous neoplasm are being presented here.

Idiopathic spontaneous rupture of unscarred uterus in a primigravida in active labour.

INTRODUCTION: Rupture of unscarred pregnant uterus is a rare occurrence and its incidence is higher in developing countries. Rupture of unscarred uterus is associated higher likelihood of adverse maternal and fetal outcomes. Occurrence of rupture of an unscarred uterus lays foundation for the importance of supervised labour and to maintain a high index of suspicion even in a prim gravida. CASE REPORT: We present a case of spontaneous rupture of unscarred uterus in a primigravida with no known risk factors. Rupture was diagnosed in second stage of labour when there was cessation of contractions and loss of station. On exploratory laparotomy, hemoperitoneum of 100 ml and a 10 cm tear was found in left posterolateral aspect of uterus. The tear was repaired successfully and patient had a normal post- operative course. DISCUSSION: Presence of a uterine scar is the key factor leading to rupture. Spontaneous rupture of unscarred uterus is a rare entity and is associated with multiple factors. In our case, all these factors were ruled out. In literature search we could find 15 cases of spontaneous rupture in unscarred uterus. According to our best knowledge this is the 7th case of rupture in unscarred uterus, reported in a prim gravida without any obvious risk factors. CONCLUSION: Rupture uterus should be kept in mind in all patients, even in primigravida if there is high index of suspicion. Quick diagnosis and immediate laparotomy is the cornerstone of treatment in such cases.

Utilization of antenatal care services and its sociodemographic correlates in urban and rural areas in Delhi, India.

INTRODUCTION: Timely and quality antenatal care (ANC) is an essential element of universal health coverage and a key determinant for the prevention of maternal mortality. Nevertheless, evidence from large-scale health surveys in developing countries highlight a lack of access and utilization of antenatal care especially among socioeconomically disadvantaged populations. METHODS: A total of 200 women were recruited from urban and rural primary care service provision areas of a government medical college in Delhi during April 2016-2017. Women with infants were interviewed to assess the antenatal care received by them during their recently concluded pregnancy. RESULTS: The mean (SD) age of the participants was 25.6 (3.9) years. A total of 63 (31.5%) participants were primigravida, and 137 (68.5%) were multigravida. The knowledge of ANC was significantly higher in the participants that were more educated (p<0.001) but it was similar in both the urban and rural sites. Only 107 (53%) participants reported receiving comprehensive antenatal care defined as early registration of pregnancy (within 12 weeks), at least four ANC visits, two doses of tetanus toxoid, and at least 100 days of iron/folic acid supplementation (IFAS). The participants lacking knowledge of ANC had three times higher odds of suboptimal ANC utilization during their previous pregnancy (p=0.018). Furthermore, the ANC content was adequate in terms of medical service provision but deficient in terms of educational and counseling services. CONCLUSIONS: A high prevalence of suboptimal ANC utilization was observed despite the availability of government-funded primary care.

The expression of p16 and galectin-3 in cervical intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC) uterine cervix.

Cervical cancer is the most prevalent cancer among women in India. The main cause of cervical cancer is persistent human papilloma viral (HPV) infection. HPV inactivates the pRb tumour suppressor protein; thus p16 expression, which is controlled by a negative feedback mechanism, is relatively increased. Galectin-3 is directly and indirectly connected to cancer cell activity and contributes to oncogenesis, angiogenesis, cancer progression and metastasis. Thus, the aim of this study was to study the expression of p16 and galectin-3 in Cervical Intraepithelial Neoplasia (CIN) and Squamous Cell Carcinoma (SCC) and to correlate p16 and galectin-3 expression. On hundred and eighteen newly-diagnosed untreated cases of CIN and SCC of uterine cervix were included in the study. Expression of p16 and galectin 3 was more pronounced in invasive SCC and High-grade Intraepithelial Lesion (HSIL), as compared to Low-grade Intraepithelial Lesion (LSIL).Thus, it may be used in clinical setting to monitor cervical lesions and to predict their progression.Impact statementWhat is already known on this subject? p16 overexpression is a surrogate biomarker of HPV infection and useful in evaluating HPV-associated squamous and glandular neoplasia of the lower gynaecologic tract. Increased galectin-3 expression is seen in SCC cervical, with less consistent results in CIN.What do the results of this study add? The results of our study adds to the growing literature that p16 and galectin-3 expression have direct statistically significant correlation with a degree of dysplasia and SCC cervix. Expression of p16 and galectin-3 was more pronounced in invasive SCC and high-grade intraepithelial lesion (HSIL), as compared to low-grade intraepithelial lesion (LSIL).What are the implications of these findings for clinical practice and/or further research? This correction of p16 and galectin-3 expression with degree of dysplasia and SCC cervix can be used for screening and early detection of cervical lesions and thus aid their early treatment and increased survival.

Prevalence of Depression and its Association with Sociodemographic Factors in Postmenopausal Women in an Urban Resettlement Colony of Delhi.

BACKGROUND: Menopause is defined as the time of cessation of ovarian function resulting in permanent amenorrhea. Menopause is associated with various symptoms such as physical, vasomotor, sexual, and psychological symptoms. Depression is a common symptom in postmenopausal women as menopause is associated with the end of the fertile period of a women's life. Menopause is an important subject to study as due to increase in life expectancy and improved health care delivery number of postmenopausal women is significantly increasing. OBJECTIVES: The objective of the study is to determine the prevalence of depression and its association with sociodemographic factors in postmenopausal women in an urban resettlement colony of Delhi. MATERIALS AND METHODS: A community-based cross-sectional study was conducted among 580 postmenopausal women who were resident of Gokulpuri in North-East Delhi, using a predesigned, pretested, and semi-structured interview schedule. Hamilton Depression (HAM-D) scale was used to find out the prevalence of depression. The collected data were analyzed using SPSS-22 version. RESULTS: In our study, 58.4% postmenopausal women were normal with no depression, 38.3% were in a mild depression, and 3.3% women were having moderate depression. Depression was more prevalent in women belonging to the younger age group, lower socioeconomic status, and illiterate women. Furthermore, the prevalence of depression was more in women who were divorced or widow. CONCLUSIONS: Study revealed prevalence of depression in significant number of postmenopausal women. To improve the quality of life of women in postmenopausal period, diagnosis of depression and relevant influencing factors is important.

Role of laparoscopy in diagnosing genital tuberculosis in suspected women: A cross-sectional study from a tertiary care hospital in Northern India.

This study was included 60 women with suspected genital tuberculosis, attending outpatient department of a tertiary care hospital. The aim was to evaluate the role and accuracy of laparoscopy in the diagnosis of genital tuberculosis. The patients were investigated for tuberculosis with Erythrocyte Sedimentation Rate, Montoux, chest X-ray, serum ELISA, CA125, ultrasonography, endometrial biopsy and laparoscopic biopsy. Culture or histopathology was taken as a gold standard for confirming the cases of genital tuberculosis. 30 patients were confirmed as positive. Comparison was made between the various diagnostic modalities. Baseline investigations like complete blood count, differential leukocyte count, ESR, Montoux, and some special tests like CA125 and serum ELISA were helpful in supporting the diagnosis in only some patients. The sensitivity, specificity, positive and negative predictive value of endometrial biopsy in diagnosing GT was 6.6%, 100%, 100% and 51.7% respectively. Laparoscopic gross visualization alone, staining, culture and histology were able to detect 86.6%, 33.3%, 50% and 63.3% of cases respectively. Many patients would have been missed if laparoscopy was not performed. It helps in macroscopic visualization of pelvic cavity and obtaining biopsies for ZN staining, culture and histopathology. This increases the pickup rate of positive cases and helps in confirmation of the diagnosis.

Evaluation of 75 g glucose load in non-fasting state [Diabetes in Pregnancy Study group of India (DIPSI) criteria] as a diagnostic test for gestational diabetes mellitus.

BACKGROUND & OBJECTIVES: There is no consensus regarding optimal standard for diagnosis of gestational diabetes mellitus (GDM). In this study, use of 75 g glucose load in non-fasting state [Diabetes in Pregnancy Study Group of India (DIPSI) criteria] as a diagnostic test for GDM in pregnant women was compared with different oral glucose tolerance tests (OGTTs). METHODS: This prospective study included 936 pregnant women, who underwent plasma glucose evaluation two hours after the challenge of 75 g glucose load irrespective of the timing of last meal (DIPSI criteria for GDM). After three days, standard 75 g OGTT was done in all women irrespective of previous plasma glucose value. Accuracy of the first result was compared to OGTT using cut-offs as per the World Health Organization (WHO) and International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for the diagnosis of GDM. RESULTS: Of the total 936 pregnant women, 73 (7.8%) patients had plasma glucose value ≥140 mg/dl when measured two hours after glucose load. When comparing with the WHO and IADPSG criteria, the sensitivity values were 65.1 and 74.1 per cent, respectively, and the corresponding specificity values were 96.3 and 96.9 per cent, respectively. On comparing with the WHO OGTT, only 41 of the 73 (56.2%) were true positives, whereas when IADPSG criteria were used, true positives were 46 (63%). False negative cases were also present when classified by the WHO and IADPSG criteria though in lesser numbers than false positives. The positive predictive values (PPVs) for the WHO and IADPSG criteria were 56.1 and 63 per cent, respectively, and their corresponding negative predictive values were 97.7 and 97.9 per cent, respectively. INTERPRETATION & CONCLUSIONS: Our findings showed that when 75 g glucose load in non-fasting state was used as a diagnostic test for GDM, almost one quarter of patients with GDM escaped diagnosis as sensitivity values were low. On the other hand, some GDM cases were falsely labelled as normal as this test did not account for cases of fasting hyperglycaemia. In addition, comparison with other OGTTs showed low PPVs. Hence, use of DIPSI criteria for diagnosing GDM must be reconsidered till further validation.

Maternal and fetal outcomes in pregnant women with Takayasu aortoarteritis: Does optimally timed intervention in women with renal artery involvement improve pregnancy outcome?

OBJECTIVE: Takayasu aortoarteritis (TA) is common in the Southeast Asian and Indian subcontinent regions with a female-to-male ratio of 8:1. Age at diagnosis is < 30 years in 90% of the cases. Because the disease is common in women of child-bearing age, management of pregnancy in these patients becomes an important issue. The purpose of this study is to evaluate the maternal and fetal outcomes in pregnancies with TA and also to evaluate whether early intervention for renal artery involvement is associated with improved outcomes. MATERIALS AND METHODS: We collected data of 12 patients with 18 pregnancies prospectively from 2006 to 2012. The patients were divided into three groups and their outcomes were noted: (1) without renal artery involvement; (2) with renal artery involvement without intervention; and (3) with renal artery involvement for which intervention has been done. RESULTS: Body mass index of patients was between 18.5 kg/m(2) and 23.2 kg/m(2). Renal artery involvement and hypertension were seen in four patients. One patient had percutaneous transluminal balloon angioplasty and another had renal artery stenting. In patients without renal artery involvement, gestational hypertension was seen in 50%, pre-eclampsia in 10%, abortion in 10%, and intrauterine growth restriction (IUGR) in 40% of pregnancies. In patients with renal artery involvement without intervention, gestational hypertension was seen in 90%, pre-eclampsia in 20%, abortion in 60%, preterm in 20%, IUGR in 20%, fetal demise in 20%, and neonatal death in 20% of pregnancies. In patients with renal artery involvement for which intervention has been carried out, gestational hypertension was seen in 66%, and abortion and IUGR were seen in 33% of pregnancies. CONCLUSION: Patients with renovascular involvement without intervention are at high risk of having maternal and fetal complications. Early intervention prior to conception in these women is recommended to prevent pregnancy complications.

Scar thickness measurement by transvaginal sonography in late second trimester and third trimester in pregnant patients with previous cesarean section: does sequential change in scar thickness with gestational age correlate with mode of delivery?

PURPOSE: The objective of this study was to evaluate whether scar thickness measured by transvaginal sonography and the sequential change in scar thickness from second to third trimester has any association with mode of delivery in patients with previous cesarean. METHODS: Pregnant women with previous one cesarean section underwent transvaginal sonography between 24 and 28 weeks of gestation and then a repeat scan beyond 36 weeks of gestation to measure scar thickness. These scar thickness measurements were then correlated with the mode of delivery. The scar was measured at multiple sites (3-4) of the lower uterine segment and its thinnest portion was considered to be the scar. RESULT: Scar thickness was thinner in those patients having cesarean delivery than those having vaginal delivery and this difference was statistically significant at both the gestational ages. Mean scar thickness at 24-28 weeks of gestation in patients who delivered vaginally is 4.8 ± 1.1 mm and in those who had repeat cesarean section is 4.4 ± 1.1 mm (p value = 0.043). Mean scar thickness beyond 36 weeks of gestation in patients who delivered vaginally is 3.3 ± 0.7 mm and in those who had repeat cesarean section is 2.9 ± 0.9 mm (p value = 0.003). The mean decrease in scar thickness was not significantly different between those who delivered vaginally (mean decrease = 1.73 ± 0.95 mm) and those who had a repeat cesarean (mean decrease = 1.91 ± 0.96 mm). CONCLUSION: Our study concluded that thicker scars are associated with better chances of successful vaginal birth after cesarean. Measurement at both late second trimester and third trimester can be done but latter has better correlation with mode of delivery. This association may be explained by the fact that thinner scars have more chances of fetal bradycardia, meconium staining of liquor and previous cesarean for feto-pelvic disproportion.

Massive spontaneous intraperitoneal hemorrhage in a young female with chronic immune thrombocytopenic purpura masquerading as ruptured ovarian cyst: successful nonsurgical management of this rare catastrophic event.

Chronic immune thrombocytopenic purpura has mild bleeding manifestations and severe bleeding requiring hospitalization is rare. We are reporting a case of a 19-year-old girl with chronic immune thrombocytopenic purpura who presented with spontaneous massive hemoperitoneum without any identifiable source of hemorrhage. We chose nonsurgical treatment over laparotomy, and the patient was managed successfully with parenteral steroids and platelet transfusion. In young women presenting with massive hemoperitoneum, undiagnosed immune thrombocytopenia should be considered as an etiology. In absence of any identifiable source of hemoperitoneum, these patients may not require laparotomy and treatment with intravenous corticosteroid and platelet transfusions may be preferrable and lifesaving.

Alternate sequential suture tightening: a novel technique for uncontrolled postpartum hemorrhage.

Objective. The most commonly described technique of modified B-Lynch suture may not be suitable for all the patients presenting with flabby, atonic uterus. Study Design. A retrospective analysis of twelve patients with uncontrolled postpartum haemorrhage, who underwent this procedure from March 2007 to September 2012, was conducted. In this novel technique, sutures are passed in the lower uterine segment and are tightened alternately to control uterine bleeding. Results. Average duration of the procedure was 4 minutes (range 2-7 minutes). Average blood loss was 1625 mL (range 1300-1900 mL). Eleven patients (91.66%) were seen to have a successful outcome with only this technique. No patient required hysterectomy and one patient (8.33%) required additional bilateral internal iliac artery ligation. All the patients had a minimum follow-up of 2 yrs and none of them reported any infertility problems. Conclusion. This technique is simple, quick, and effective. There was no adverse effect on the fertility potential for the observed 2 years; however, a long-term follow-up is required to comment on its actual rate. This technique cannot replace the standard modified B-Lynch technique for uncontrolled postpartum haemorrhage but can be used for unresponsive, flabby, and atonic uterus.

Varied presentation of uterine arteriovenous malformations and their management by uterine artery embolisation.

Uterine arteriovenous malformations are rare lesions which have a varied presentation that may range from the patient being asymptomatic to varying degrees of menorrhagia. It can be diagnosed by Doppler sonography but a strong index of suspicion is necessary. Management of this condition depends on presentation and available resources. In asymptomatic patients, we can leave the patients on regular follow-up as many lesions regress spontaneously. In patients with excessive haemorrhage not responding to embolisation or when facilities of embolisation are not available, hysterectomy needs to be done. Uterine artery embolisation should be considered the optimum treatment, as it has a high success rate coupled with few complications and also has fertility-preserving potential. Clinical follow-up usually suffices but sonography may occasionally be required.

Comparison of scar thickness measurements using trans-vaginal sonography and MRI in cases of pregnancy with previous caesarean section. Do they correlate with actual scar thickness?

The aim of this study was to evaluate scar thickness in cases of pregnancy with previous caesarean section, by trans-vaginal sonography (TVS) and magnetic resonance imaging (MRI), and to correlate precision of radiologically-measured scar thickness with actual measurement of scar thickness. A total of 35 pregnant patients with previous caesarean section planned for elective caesarean section, were evaluated prospectively. Their scar thickness was measured by TVS and MRI on the day of elective repeat caesarean section. These measurements were correlated with each other and with scar thickness measured during elective repeat caesarean section by using a caliper. The correlation coefficients between scar thickness measured by TVS and MRI with peroperative evaluation with a caliper, were +0.72 and +0.59, respectively. The study concluded that as MRI is a costlier modality and TVS has better correlation coefficient with actual scar thickness, TVS can be considered to be the better modality for antenatal scar thickness measurement.

Fatal methotrexate toxicity: could it have been avoided?

Methotrexate is used judiciously, only when specifically indicated. However, in this case the patient had a fatal outcome after only three doses. A young nulliparous woman diagnosed as having high-risk persistent trophoblastic disease was considered for multidrug chemotherapy. However, because of persistent low-grade fever it was decided to give only single agent, methotrexate. She developed severe toxicity which proved fatal, even before the first course could be completed. Analysing causes of this rare, unexpected outcome of methotrexate administration, suggested that estimation of serum levels can be a useful tool in monitoring patients showing hypersensitivity but this facility is rarely available especially in low-resource countries. Pharmacogenetical analysis of blood/tissue sample may be useful to help in identifying patients likely to show hypersensitivity reaction.

Safety and efficacy of low molecular weight heparin therapy during pregnancy: three year experience at a tertiary care center.

PURPOSE: To evaluate safety and efficacy of low molecular weight heparin given for various indications during pregnancy. METHODOLOGY: A detailed retrospective analysis of all the patients who received low molecular weight heparin (LMWH) for various indications over a period of 3 years (2010-2012) at a tertiary care hospital in Northern India was performed. RESULTS: Fifty-five patients received LMWH over the period of 3 years, for various indications. Enoxaparin (1 mg/kg body weight OD/BD subcutaneously) was used. The indications were valvular heart disease with valve replacement, atrial fibrillation, or thrombus in 60 % patients; chronic deep vein thrombosis (DVT) in 7 % patients; thrombophilia in 9.1 % patients; recurrent pregnancy losses in 18 % patients; and DVT prophylaxis in 5.5 % patients. Abortion was seen in 7.2 % patients; fetal growth restriction in 10.9 % patients; and oligohydramnios, preeclampsia, gestational hypertension, placenta previa, abruptio placentae, and postpartum hemorrhage in 1.8 % patients. Stillbirth occurred in 3.6 % patients. No thromboembolic event was noted in any of the patients. None of the patients had any documented thrombocytopenia or clinical fracture. CONCLUSION: Low molecular weight heparin can be used in pregnancy for various indications as an alternative to unfractionated heparin or warfarin as it is efficacious and safe.

Clinical evaluation of severe anemia in pregnancy with special reference to macrocytic anemia.

AIMS: Anemia in pregnancy has been almost synonymous with iron-deficiency anemia but there appears to be a changing trend with emerging evidence of macrocytic anemia. The aim of this study was to evaluate the clinical profile of patients having severe anemia in pregnancy. METHODS: This study included all antenatal patients presenting with severe anemia (hemoglobin<7gm%) over a period of 2years from January 2008 to December 2009 in the Department of Obstetrics and Gynaecology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi. RESULTS: Although iron-deficiency anemia remains the most important cause of anemia (48.1%) there is also a high prevalence of macrocytic anemia (40%) amongst these cases of severe anemia in pregnancy. The maternal and fetal morbidity and mortality is higher in macrocytic anemia as compared to iron-deficiency anemia. CONCLUSION: There is an emerging trend of macrocytic anemia among antenatal patients with severe anemia. Both maternal and fetal morbidity appears to be higher in these cases. This has important implications in terms of diagnosis and therapy to optimize both maternal and perinatal outcomes. Once clinicians and health administrators recognize the magnitude of this problem it may be considered relevant to start public health interventions by way of requirement of appropriate food fortification.

Lower genital tract infections in HIV-seropositive women in India.

OBJECTIVES: The presence of STD facilitates shedding of HIV and increases HIV-1 disease progression, possibly by increasing plasma viremia. Our aim was to study the presence of various associated Sexually transmitted disease/Reproductory tract infections in HIV-seropositive women in India. MATERIALS AND METHODS: The study included 40 HIV-seropositive women attending the antiretroviral therapy (ART) clinic at Lok Nayak Hospital. An informed consent was taken from all subjects. All cases were subjected to detailed gynecological examination and two types of swabs, i.e., a vaginal swab and a cervical swab were taken for STD/RTIs evaluation. The vaginal swabs were used for preparation of wet mount and KOH mount for diagnosis of trichomoniasis and candidiasis; to make a vaginal smear for Gram staining to diagnose bacterial vaginosis (BV) as per Nugent's criteria; for culture of aerobic bacteria and Candida spp. The cervical swab was used for isolation of Neisseria gonorrhoeae by culture and for detection of Chlamydia trachomatis antigen by Chlamydia microplate enzyme immunoassay kit (BIORAD). All data were analyzed using appropriate statistical tests. RESULTS: All 40 cases were evaluated for the presence of STD/RTIs associated with HIV infection. The women belonged to the reproductive age group (15-45 years) and majority (40%) of them were para 2. Most of the women (14, 35%) were in World Health Organization (WHO) stage I and maximum number (28, 70%) had their CD4 cell count more than 200 cells/ml. There was no significant correlation between WHO stage of HIV-seropositive women and their CD4 cell count (P=0.092). Out of 40 cases, 15 (37.5%) were on ART with maximum cases (53.3%) in WHO stage III. The duration of ART was more than 6 months in 9 (60%) cases. The most common presenting complaint was vaginal discharge in women with WHO stage II and III and 27.5% women showed vaginitis on per speculum examination. Laboratory tests showed high prevalence of BV (30%), mixed infection (30%), and candidiasis (10%) among HIV-seropositive women (P<0.001 in both). Women with BV were mostly in WHO stage I (38.4%) and stage II (36.3%), while those with mixed infection were mainly in WHO stage III (36.3%) and stage IV (40%).Women with candidiasis were mainly in WHO stage III. C. trachomatis antigen was found only in one subject (prevalence 2.5%). Both WHO stage and CD4 cell count had no significant correlation with presence of BV (P=0.056 and 0.063, respectively) and candidiasis (P=0.492 and 0.530, respectively). Maximum number of patients on ART had mixed infection (53.3%), while most of the patients (36%) not on ART had BV. There was no significant association between duration of ART and the presence of vaginal infections. CONCLUSIONS: The prevalence of gynecological symptoms and RTIs in HIV-seropositive women is high enough to warrant routine gynecologic evaluation and RTI screening in these patients. However, larger studies and trials are needed to evaluate the effects of ART on these abnormalities as well as to choose the best screening tool in HIV-seropositive women.

Pelvic angiomatosis: an unusual cause of recurrent obstructed labor: a case report and review of literature.

BACKGROUND: Pelvic angiomatosis is a very rare cause of obstructive labor. MATERIALS AND METHODS: A 26-year-old P2 L2 had two cesarean sections for recurrent obstructed labor due to a large pelvic mass. Investigations after the first cesarean section suggested a benign nature of the mass for which she was advised surgical resection, but she refused due to social reasons. Tumor had pelvic and extrapelvic part extending through obturator foramen into the right thigh. Resection of the pelvic part by abdominoperineal approach led to a profusely bleeding bed which was managed by ligation of bilateral internal iliac artery. Resection of extrapelvic part was attempted but it was abandoned due to hemodynamic instability of the patient. RESULTS: Patient is asymptomatic and is having a relatively static residual extrapelvic part of pelvic tumor for last 2 years. CONCLUSION: Pelvic angiomatosis is a very rare condition but should be considered and ruled out in case of a pelvic mass of uncertain origin. MRI plays an important role in the initial diagnosis, in surgical planning and in the follow-up in order to detect recurrences. Surgical resection should be as conservative as possible, balancing the need for complete surgical extirpation with the morbidity of the procedure.