BULGARIAN PATIENT WITH ATROPHODERMA OF PASINI AND PIERINI- DESCRIPTION OF A CASE AND SHORT UPDATE.

Atrophoderma of Pasini and Pierini is a rare, considered benign, skin disease characterized by single or multiple asymptomatic atrophic plaques. Lesions can occur everywhere on the body with the trunk being the most often reported affected site. It appears in the second or third decade of life and affects mostly the female population, with male to female ratio of 1:6, commonly of white European descent. Different risk factors were described in the literature - genetic predisposition, infections with Epstein-Barr virus, varicella zoster and Borrelia burgdorferi, vaccinations, local trauma and more. Since the pandemic with COVID-19, skin manifestations after the viral infection with COVID-19 were reported. After a thorough search of the existing medical literature, we believe, we present the first case of a rapid progression of Atrophoderma of Pasini and Pierini after COVID-19 infection. Due to its similarity to morphea in some aspects, the condition is often misdiagnosed, and the proper treatment is often delayed. Sometimes the dilemma "Is it atrophoderma Pasini-Pierini or is it in fact morphea?" stays, but the exact histopathological verification and the "diagnostic clues" which can be used during the examination stage, are usually enough to diagnose the condition. We present a 63-year-old female with a rapid progression of atrophoderma of Pasini and Pierini after a COVID-19 infection. The lesion that she presented with was single, asymptomatic, with central hypopigmentation and slight atrophy, with a smooth, shiny surface and ivory color, and peripheral hyperpigmentation, measured 18x5cm, without the presence of perilesional erythema. The patient was initially diagnosed clinically with localized scleroderma (morphea) and treated with hydroxychloroquine 200 mg once daily for a 5-year period without improvement. Years later two biopsies from different lesional sites were taken, resulting in absence of sclerosis and dermal atrophy, but - reduction in the thickness of the dermis with fragmentation and hyalinization of collagen fibers forming a parallel orientation, dilated vascular vessels of small caliber and reduced number of skin appendages, confirming the diagnosis of atrophoderma Pasini-Pierini. The patient's therapy was switched to methotrexate with good therapeutic response. Often, the two conditions - morphea and atrophoderma of Pasini and Pierini can be mistaken due to its clinical similarity and sometimes coexistence. Therefore, we will shortly review the existing literature with key points on the similarities and differences.

[Assessment of the efficacy of the Tot'hema at anaemic status with different severity in the obstetric and gynecologic practice].

Iron deficiency anaemia affect every fifth person on the planet, including the developed counties, too; the last data are that at about 700 000 000 are affected. The most common reasons for iron deficiency anemia in the obstetrics and gynecology are: pregnancy and menopause, chronic haemorrages/menorrhagiae and metrorrhagiae/dysfunctional uterine bleeding, myoma uteri, neoplastic diseases/, acute anaemias post partum and after operative interventions. The aim of the present study is to study the efficacy of the treatment of iron deficiency anemia at women with different obstetrics and gynecology pathology.

[Single umbilical artery (SUA)].

Single umbilical artery (SUA) is the most common abnormality of the umbilical cord. It is associated with an increased incidence of atresia of hollow organs, renal abnormalities, limb reduction defects and spontaneous abortions. The aim of our study is to establish the association of SUA with types of malformations and the corresponding pathology of pregnancy and parturition. Although our investigation is in proof of the association of SUA with anomalies of GIT, CCS and CNS, most of our cases exhibit circulatory disturbances leading to pathology of pregnancy and delivery.

[Modern tendencies in treatment of endometrial cancer].

AIM: We tried to summarise our and foreign experience in the modern treatment of endometrial cancer. MATERIAL AND METHODS: We evaluated for 10 years period 400 patients treated surgically, as well as treated with postoperative radiotherapy. We tried to give the allgorhythm for treatment of this kind of cancer. All patients with grading 3 tumors, serous-papillary and clear cell endometrial cancers are obligatory are staged surgically. In some of our patients we performed pelvic lymph node dissection with or without paraaortal dissection which brought a more precise information. RESULTS: In patients with pelvic and paraaortal lymph node dissection (200) we had significantly better overall survival rate (p = 0.0003), as well as better survival rate both in low risky and high risky groups (low risky groups p = 0.028, high risky groups p = 0.0007). CONCLUSIONS: The therapeutic benefit of this method is in resecting of the enlarged, positive lymph nodes, which can not be sterilized with radiotherapy. The postoperative intravaginal and percutaneous radiotherapy save these patients from vaginal recurrences.

[A case of heterotopic pregnancy].

Heterotopic pregnancy is the simultaneous occurrence of intrauterine and ectopic pregnancy. Because of the increasing use of assisted reproductive technology techniques, the frequency of heterotopic pregnancy rises during the past years. We present a case of simultaneous occurrence of ruptured extrauterine /tubal/pregnancy and intrauterine /twin/pregnancy after IVF and ET.

[HELLP syndrome, complicated with DIC syndrome in the third trimester of pregnancy].

Defined as hemolysis, liver dysfunction and low platelets, HELLP syndrome is a severe complication of preeclampsia with worsening seriously the prognosis of mother and foetus. Frequently it is associated with the development of DIC syndrome. We present a case of HELLP syndrome developed in 30 gestational week, complicated with DIC syndrome.

[Mixed gonadal dysgenesis combined with gonadoblastoma].

Gonadal dysgenesis is defined by incomplete or defect forming of gonads, a result of disturbed process of migration of germ cells or and their correct organization in gonadal ridge. The combination of dysgenetic gonads and Y chromosome is a prerequisite for developing ovarian neoplasma--most frequent gonadoblastoma. We present a case of mixed gonadal dysgenesis at a patient with caryotype 46XY in combination with gonadoblastoma.

[A clinical case of twin pregnancy with intrauterine death of one of the twin (foetus papiraceus)].

Multiple pregnancy is associated with some specific syndromes: twin to twin transfusion syndrome, syndrome of the disappeared twin, intrauterine loss of one of the twin, development of foetus papiraceus and syndrome of asymmetric growth of the twin. We present a case of term pregnancy with death of one of the twin and normal delivery of healthy baby and Foetus papiraceus.

[Ovarian cancer with metastatic lesion in the vagina (foetus papiraceus)].

Ovarian cancer spreads primarily by intraperitoneal implantation of exfoliated cancer cells, by lymphatic dissemination, and by haematogenous spread. Very rarely it metastasizes to cervix, vulva and vagina; this type of metastases present a diagnostic challenge to the gynecologist and pathologist. We present a case of ovarian cancer with initial clinical manifestation-lesion of the vagina.

[Immunohistochemical profile of colorectal and ovarian carcinomas--examination with cytokeratin 7, cytokeratin 20, beta catenin and cDX 2].

INTRODUCTION: Metastases from colorectal adenocarcinomas can be histologically similar to serous, mucinous and endometrioid ovarian adenocarcinomas. The differentiation between primary and metastatic ovarian tumours is of great importance for the patients because of the different treatment and prognosis. AIM: The aim of the study was to determine whether the differences in the expression of Cytokeratin 7, Cytokeratin 20, Beta catenin and CDX2 can be used to distinguish the different types of carcinomas and their metastases. MATERIALS AND METHODS: The immunohistochemical expression of the listed above antibodies was examined retrospectively and prospectively in 38 colorectal adenocarcinomas (primary and metastatic) and 32 ovarian adenocarcinomas (primary and metastatic). The metastases in both types of adenocarcinomas are located in the peritoneum. RESULTS: The immunohistochemical expression was evaluated using a semi-quantitative method. The ovarian adenocarcinomas are mostly positive for Cytokeratin 7 (in 63%), while colorectal carcinomas are mostly positive for Cytokeratin 20 (in 73%). Regarding Beta catenin, in colorectal carcinomas the expression is mostly nuclear (in 65%) and in ovarian carcinomas mostly membrane (in 68%). In cases of uncertain expression of the markers mentioned above, CDX2 was used. Positive nuclear expression was observed only in intestinal tumours (in 86%). CONCLUSION: For differential diagnosis between ovarian and colorectal adenocarcinomas, the use of antibodies, determining the intestinal differentiation of the tumours like Cytokeratin 20, Beta catenin and CDX2 is recommended.

[Our experience in the surgical treatment of advanced endometrial cancers].

AIM: Our aim was to summarise our experience in the surgical treatment of advanced endometrial cancers for 20 years period. MATERIAL AND METHODS: The patients were treated surgically by extrafascial hysterectomy, radical hysterectomy with pelvic and paraaortal lymph node dissection, by pelvic exenteration and by cytoreductive surgery (350 patients). The radical hysterectomy was applied in patients with stage II endometrial cancer. RESULTS: When cytoreductive surgery was used, we observed difference in the five years survival rate when the residual tumour was < or = 2 cm and > 2 cm in diameter. Better survival rate was observed in the first group with < or = 2 cms in diameter. The five years survival rate in patients treated with radical hysterectomy versus patients treated by extrafascial hysterectomy was 89% vs.68%. In patients with pelvic and paraaortal lymph node dissection the survival was 69%, while in patients only with pelvic dissection was 38%. According to our results the aggressive cytoreductive surgery betters the survival in endometrial cancer stage III-IV. CONCLUSIONS: The improvement in the adjuvant therapy may give an additional light in the treatment of advanced endometrial cancers. The radical hysterectomy with pelvic and paraaortal lymph node dissection improves significantly the overall survival rate of these patients. The optimal cytoreduction also leads to improvement of the survival in patients with advanced endometrial cancers.

[Uterine carcinosarcoma with chondroid differentiation--immuhistochemical examination].

Uterine carcinosarcomas are highly aggressive malignant tumours, consisting of both epithelial and mesenchymal components. They represent 1-3% of the malignant uterine neoplasms. Their histogenesis is unclear. Because of their rarity and the very few clinical data available, the studies of potential therapeutic goals are scarce. We present clinical and pathohistological description of a rare case of a 76-year-old woman with a uterine carcinosarcoma with a chondroid differentiation, examined immunohistochemically with Cytokeratin, Vimentin and S-100 protein.

[Meconiophages and fetal hypoxia].

Meconium may normally be passed by term fetuses during labour. Common after 40 weeks and not a sign of fetal distress Before 40 weeks can implicate fetal distress If occurring in preterm fetuses or if present prior to labour, it may be considered a possible indication of fetal distress. Histopathology may estimate the duration of meconium passage. Macrophages containing meconium are present at the chorionic surface or deeper portions of the membrane and can be easily identified not only on routine hematoxylin-eosin staining but also with the help of immunohistochemistry.

[CDX2--an immunochystochemistry marker of intestinal differentiation of adenocarcinomas].

CDX2 is a nuclear transcribing factor, important for the development and differentiation of the bowels. According to the recent publications, CDX2 expression is immunochystochemisry detector in the normal enterocytes of the bowels and is normally met in the most, but not at all colorectal carcinomas. Two homeostatic genes are detected at people CDX1 u CDX2. We present examination of CDX2 expression at 15 adenomas and 30 colorectal carcinomas. All the adenomas are positive for CDX2, 27 /90%/ of the adenocarcinomas show nuclear expression of CDX2.

[Frequency of cytolytic vaginosis--examination of 1152 patients].

The aim of the study was to evaluate the frequency of cytolitic vaginosis amongst women with symptoms that mimic vulvovaginal candidiasis. We include 1152 patients, which are microbiologically and citologically tested. We found in 3.9% cytolytic vaginosis. The clinical presentation is suggestive of vulvovaginal candidiasis. The differentiation of these two conditions is essential for appropriate treatment and resolution of chronic vaginal subjective complaints.

[Differential diagnostic importance of immunochistochemistry applied at metastases of adenocarcinomas of the peritoneum].

Patients with metastatic carcinomas with unclear primary tumor site are often clinical and pathological problem. They are diagnosed in about 3-65 of the cases with solid tumors. In 60% of cases the reason is adenocarcinomas. The most frequent reason for peritoneal carcinomas at women is the ovarian cancer. In such cases we must exclude the probability of colorectal cancer. In fact there are not international standards for prove the origin of adenocarcinomas; different research groups use different criteria. We present the use of four antibodies--Cytokeratin 7 and 20, Beta cathenin and CDX2 and define their positiveness at metastases from different groups of adenocarcinomas in the peritoneum.

[Molecular genetics of ovarian cancer].

Ovarian cancer is the most lethal gynecologic neoplasia. The risk of ovarian cancer in Europe is 1 to 80. In 80-90% of cases, the clinical manifestation is in advanced stage. The 5 year survival is for III /IV stage 25%, but for I/II stage is 90%. In the present study we present the molecular and genetic changes of hereditary and sporadic ovarian cancer.

[Adnexal torsion and concominant appendicitis during third trimester of pregnancy--a case report].

Adnexial torsion is a rare, but important cause for abdominal pain during pregnancy. During pregnancy, its frequency is 10-20%, with highest frequency in the first trimester. We present a case of 24 year primigravida, with an acute onset of clinical symptoms with concominant disease chronic pyelonephritis. The initial diagnosis was exacerbation of the concominant disease and acute inflammation of the appendix. The intraoperative diagnosis was right adnexial torsion and inflammation of the appendix; the diagnosis was pathologically proved. Although rare, it can be included in the differential diagnosis of acute abdomen during pregnancy.