Primary melanoma of the vagina: a case report and review of literature.

Summary Primary melanoma of the vagina is a rare and very aggressive tumor with an incidence of only 0.46 per one million women per year and less than 250 cases reported in the literature. Here the authors present a case of a 60-year-old woman, gravida 5, para 5, post-menopausal by 28 years, admitted to the Clinic for Obstetrics and Gynecology, with recurrent vaginal bleeding for the last year and with the complaint of a palpable tumor near the vaginal introitus. The preoperative biopsy revealed melanoma. CT scan did not prove she had distant metastasis. The patient was treated surgically, with wide local excision of four x five cm measured lesion and safety margins of two cm. Bilateral inguinal lymphadenectomy was performed. Follow-up five months after initial diagnosis, revealed no evidence of local recurrency or distant metastasis.

Predictive factors of malignancy in patients with adnexal masses.

INTRODUCTION: Good preoperative tumor triage is essential for choosing the appropriate approach. OBJECTIVE: The study aim was to identify factors from standard preoperatively collected data, which could predict the nature of adnexal masses prior surgery. MATERIAL AND METHODS: The study involved all women treated in the Clinic for Gynecology and Obstetrics Clinical Center of Serbia for adnexal tumors throughout a period of 18 months. On admission, detailed anamnestical and laboratory data were obtained and ultrasound scans were performed. Obtained data were compared with hystopathological findings of tumors. Methods of correlation and logistic regression were applied to create association models. RESULTS: Three new models for predicting tumor nature were achieved from anamnestical data, characteristics of women and tumors, and laboratory analyses. Two statistically significant (p = 0.000) equations were obtained for anamnestical data and characteristics of women and tumors, while three were made for laboratory analyses. Sensitivity of anamnestical malignancy index (AMI) was 73.33%, specificity 72.87%, positive predictive value (PPV) 39.49% and negative predictive value (NPV) 91.88%. Sensitivity of characteristic malignancy index (CMI) was 92.38%, specificity 67.36%, PPV 40.59% and NPV 97.34%. Sensitivity of laboratory malignancy index (LMI) was 56.45%, specificity 90.24%, PPV 68.63%, and NPV 84.57%. CONCLUSIONS: The best predictors of malignancy are menopausal status, body mass index (BMI), age, metastases, ascites, tumor marker CEA level, and erythrocyte sedimentation rate (ESR). Along with the risk of malignancy index (RMI), for more reliable triage and preoperative tumor evaluation the authors propose introduction of another three indexes (AMI, CMI, LMI) in clinical practice.

Conservative management of massive hematoperitoneum caused by ovulation in a patient with severe form of von Willebrand disease--a case report.

Von Willebrand disease (VWD) is the most common inherited bleeding condition that involves extended or excessive bleeding, caused by the deficiency or defect of von Willebrand factor (VWF). Hematoperitoneum as a complication of gynecologic diseases represents acute condition which is usually caused by the hemorrhagic corpus luteum or a rupture of either ectopic pregnancy or a hemorrhagic ovarian cyst. The authors present a unique case of conservatively managed massive hematoperitoneum caused by ovulation in a patient with severe form of von Willebrand disease who had right adnexectomy due to hemorrhagic corpus luteum four months prior. This conservative management by blood product and factor concentrate support could be a method of choice in selected hemodynamically stable patients. Furthermore, recurrent bleeding episodes following ovulation could be prevented by suppression of ovulation using oral contraceptive pills.

Radical abdominal trachelectomy in managing early cervical invasion.

The purpose of the study was to determine if radical abdominal trachelectomy with pelvic lymphadenectomy could be a method for treatment of early cervical cancer to preserve fertility. We examined 12 patients who were surgically treated from 2002 to 2006. The diagnostic method to determine cervical cancer was histologic examination by cone or biopsy. The histologic condition was well differented planocellular carcinoma. Two of the patients had Stage Ia1, seven had Ia2, and three had Ib1. We performed radical abdominal trachelectomy with pelvic lymphadenectomy. Resection edges were pathohistologically analyzed extemporaneously, as well as selective lymph nodes. According to the extempore analysis we determined if radical trachelectomy should be done. In one patient resection edges were positive, so she underwent radical hysterectomy. Postoperatively we found a positive lymph node in one patient, so radiation therapy was continued. In the two-year follow-up period we did not find any signs of residual cancer. We concluded that radical trachelectomy with pelvic lymphadenectomy could be an appropriate method for treatment of early-stage cervical cancer.

Retroperitoneal "Triton" tumor.

Malignant Triton tumor is a malignant peripheral nerve sheat tumor with rhabdomioblastic differentiation. These tumors are frequently associated with Neurofibromatosis type 1, sporadic cases being exteremly rare. Retroperitoneal localization have the most unfavorable prognois due to delayed diagnosis but also due to relation to adjacant organs. Preoperative diagnosis is inaccurate, but core needle biopsy gives more promising results. Aggressive surgical management remains the most effective modality since adjuvant forms of treatment like irradiation or chemotherapy do not have reproducible results. We present a 60-year-old female patient in whom a retroperitoneal presacral mass was postoperatively diagnosed as Triton tumor. At time of diagnosis, no visible metastases were present. The posterior pelvic exenteresis was performed. Intended chemotherapy was never started since multiple pulmonary, hepatic and splenic metastases were diagnosed only a month after surgery, with rapid lethal outcome. This case demonstrates the bad prognosis of malignant retroperitoneal tumors. Diagnostic tools such as refined biopsy techniques or cytogenetic analysis might help in differentiating patients who will benefit from radical surgery.

[Radical treachelectomy in treatment of early stages of cervical cancer].

The aim of the study was to determine if radical trachelectomy with pelvic lymphonodectomy could be a method for treatment of early cervical cancer to preserve fertility. We examined 12 patients who were operatively treated from 1996. to 2006. year. Diagnostic method for cervical cancer was histologic examination, cone or biopsy. Histologic condition was planocelular carcinoma well differented. Two of the patients had Ia1 stage, seven had Ia2, and three of them had Ib1. We performed abdominal radical trachelectomy with pelvic lymphonodectomy. Resectional edges were patohistologically analyzed ex tempore, as well as lymphonodi, selectively. According to ex tempore analysis we determined if the radical trachelectomy should be done. In one patient resectional edges were positive, so she underwent radical hysterectomy. Postoperatively we found a positive lymphonodus in one patient, so we continued radiation therapy. In two-year follow-up period we did not find any sign of residual cancer. We concluded that radical trachelectomy with pelvic lymphonodectomy could be appropriate method for treatment of early stage cervical cancer.

[Outcome of Burch retropubic urethropexy and the effect of concomitant abdominal hysterectomy].

A prospective follow-up stady was performed to evaluate the effect of Burch colposuspension alone and a concomitant abdominal hysterectomy with Burch colposuspension. Twenty seven women underwent Burch colposuspension and 34 women colposuspension with abdomina hysterectomy. Subjective outcame was assessed with questionaire at 4 weeks, 6 months and 1 year. In the 1 year follow-up 81,4% were subjectively cured or improved in the Burch group and 76,4% in the hysterectomy group. No statistically significant difference in the frequency of any subgroup of complications was found.

New approach of the treatment of von Willebrand's disease during pregnancy.

AIM: The aim of the study was to analyze the effectiveness of the application of DDAVP (desmopressin) and Hemate P with cryoprecipitate pre- and postpartum in patients with von Willebrand disease. METHODS: We monitored 32 patients with von Willebrand disease during the study period 1993-2003. DDAVP was applied in the 36th/37th week of gestation and cryoprecipitate and fresh frozen plasma were applied 1 day before and 3 days after delivery. DDAVP treatment continued for 4 weeks. Factor VIII (Hemate P) at the day of delivery RESULTS: No complications occurred in the studied population. CONCLUSION: Precipitation of DDAVP, Hemate P, and cryoprecipitate may help in the treatment of pregnant women with von Willebrand disease.

The significance of Doppler flow in early detection of uterine sarcoma in older primigravida pregnancies.

During a four-year period we analyzed the significance, sensitivity and sensibility of myoma Doppler flow during pregnancy in relation to the course and outcome of the pregnancy and to later histopathological findings. By following 36 older primigravidas with determined myomas, we observed the course of the pregnancies in all trimesters and analyzed myoma Doppler flow. In conditions where the resistance index showed the possibility of uterine sarcoma, the pregnancy was ended by surgery; not only was myomectomy performed but also complete uterine hysterectomy with the previous consent of the patient. Doppler flow was accepted as the authoritative parameter for non-invasive detection of a malignant process. Considering the obstetrical findings, other patients were delivered vaginally or operatively, but after puerperium they were subjected to control examinations and myomectomy because Doppler flow findings did not show any indications of sarcoma. By histopathological analysis, we received benign results in 31 cases, while in four cases where we decided on hysterectomy and surgical delivery, we received malignant results, i.e. leiomyosarcoma. In four cases of performed hysterectomy immediately after cesarean section, the resistance index (RI) of revascularization within the myoma was in the range between RI 0.30 +/- 0.02. Flows within the uterine artery were 0.54 +/- 0.03.