The management of adnexal masses in premenopausal patients: a ten-year retrospective study at a single center.

PURPOSE OF INVESTIGATION: To distinguish adnexal masses as benign and malignant, and to thereby identity the suitable surgical method for these masses, in premenopausal women, by retrospectively evaluating over a ten-year period, the diagnostic parameters, such as serum CA 125 and transvaginal ultrasonography (TVS), in combination with the presence of ascites in the abdomen. MATERIALS AND METHODS: The study was conducted with 255 premenopausal patients diagnosed with adnexal masses who had been admitted to the Gaziantep University Faculty of Medicine, Clinic of Gynecology and Obstetrics, between January 2003 and January 2013. Data collected from these patients included age, menopausal state, information regarding the presence of ascites, ultrasound findings, and serum CA 125 levels. RESULTS: The mean age of the women included in the study was 32.79 ± 8.11 (range: 18-51) years. Based on the criteria mentioned above, 152 patients were treated by laparoscopy based on a strong suspicion of benign mass, while 103 patients were treated by laparotomy, based on a strong suspicion of malignant mass. CA 125 values did not have a significant effect on malignancy risk. Based on the TVS results, three malignant masses were reported postoperatively in the patient group strongly suspected to have benign masses, while five benign masses were reported postoperatively in the patient group strongly suspected to have malignant masses.An evaluation of the present diagnostic method showed that the TVS has a positive predictive value (PPV) of 94.19% in identifying malignant masses, and a negative predictive value (NPV) of 98.22% in identifying benign masses. CONCLUSION: TVS and CA 125, along with an evaluation of menopausal status and ascites, can be an effective approach for diagnosing adnexal masses, and also for determining the proper surgical method to follow.

Assessment of ß-hydroxydeoxyguanosine levels in patients with preeclampsia: a prospective study.

PURPOSE OF INVESTIGATION: To determine the levels of 8-hydroxydeoxyguanosine (8-OHdG) in preeclampsia (PE) using (enzyme-linked immunosorbent assay (ELISA) method. MATERIALS AND METHODS: Twenty-two pregnant women with severe PE, 18 pregnant women with mild PE, and 40 healthy pregnant women, all between 25 and 41 weeks of gestation, were enrolled in this prospective controlled study. 8-OHdG levels in maternal serum were measured using ELISA method. RESULTS: The authors observed no statistically significant difference in 8-OHdG levels between the mild-severe PE and control groups (p = 0.208). CONCLUSION: The present results do not support the concept that 8-OHdG has a role in the etiopathogenesis of PE.

Evaluation of sialic acid levels in patients with hydatidiform mole: a preliminary study.

PURPOSE OF INVESTIGATION: This study aims to investigate whether hydatidiform mole (HM) disease with malignant potential is significantly associated with increased sialic acid (SA) levels. MATERIALS AND METHODS: A total of 114 women were enrolled in this study. Patients were divided into three groups including HM (Group 1, n = 34), control group including non-pregnant healthy patients (Group 2, n = 42), and another control group including healthy pregnant patients within 12 weeks of gestation (Group 3, n = 38). Serum-free SA levels were measured. RESULTS: There was a statistically significant difference in serum-free SA levels among the groups (p ≤ 0.001). Patients with HM had significantly higher levels compared to the control groups. CONCLUSION: The present study results showed that there was a significant correlation between HM and serum SA level.

Do high levels of CA 19-9 in women with mature cystic teratomas of the ovary warrant further evaluation?

PURPOSE: To evaluate the serum levels of tumor markers (particularly CA 19-9) in patients with ovarian mature cystic teratomas (MCT) with respect to age, size, bilaterality, menopause, presence of adhesions, complications and the postoperative levels. METHODS: We evaluated clinical characteristics and tumor markers of 157 patients with MCT of the ovary operated at our clinic. RESULTS: CA19-9 was the only tumor marker with a mean serum level (46.95 +/- 101.11 U/ml) above the cut-off value and the elevated rate was 33.1%. Tumor size, presence of adhesions and CA 125 levels were significantly higher in patients with elevated CA 19-9. Bilaterality rate was 10.8%. The most common complication was torsion (6.4%). CONCLUSION: We suggest that elevated levels of CA 19-9 may be expected in MCTs of the ovary and that they will probably be decreased postoperatively. Therefore, postponing evaluation of other possible sources of CA 19-9 elevation in asymptomatic and young patients is more common sense.

Good prognosis for primary ovarian pure nongestational choriocarcinoma using the EMA/CO regime.

Nongestational choriocarcinoma of the ovary is a rare germ cell tumor with a worse prognosis than gestational choriocarcinoma. In this report we present a case of nongestational chroriocarcinoma where the EMA/CO regime was applied. The clinical features, management, and outcome are discussed.

An analysis of hysteroscopy experience over a seven-year period.

PURPOSE OF INVESTIGATION: Over the years, hysteroscopy has been increasingly performed for various gynecological disorders. In this study, we present a review of hysteroscopic procedures performed over a 7-year period. METHODS: Five hundred and eighty hysteroscopic procedures performed at the Department of Gynecology and Obstetrics, University of Gaziantep, Turkey from 2002 to 2009 were reviewed particularly highlighting the preoperative indications, postoperative diagnoses and complications associated with the procedure retrospectively. RESULTS: The most common indication for diagnostic hysteroscopy was infertility followed by AUB. The most common pathologies for referal to operative hysteroscopy were uterine septum, endometrial polyps, Asherman's syndrome, submucous myomas, and other uterine anomalies. The complication rate was 0.86% of the total hysteroscopies. False passage and uterine perforation were the most common acute complications. No late complications occurred. CONCLUSION: Our data is consistent with reports from other studies supporting that hysteroscopy is a safe and effective minimally invasive procedure with a low rate of complications with certain surgical principles.

Uterine myoma in pregnancy: report of 19 patients.

PURPOSE OF INVESTIGATION: To evaluate the effect of pregnancy on uterine myoma and the effect of uterine myoma on the pregnancy prospectively. METHODS: Prospective evaluation of 19 pregnant women with uterine myomas was done between January 2005 and February 2008 at the Gynecology and Obstetrics Department Gaziantep University. The number and changes in size of the uterine myomas during pregnancy, and perinatal complications were documented. RESULTS: Totally 37 fibroids in 19 pregnant women were observed. Neither enlargement of myomas nor serious perinatal complications were observed. CONCLUSION: We suggest that in contrast with the general opinion there is not much effect of pregnancy on uterine myoma size, and most cases are not affected by the presence of uterine fibroids resulting in severe perinatal complications. Expectant management may be an option for uterine myomas determined before gestation.

SodiumPhosphate (NaP) versus polyethylene glycol-electrolyte lavage solution (PEG-ELS) tolerability: a prospective randomized study in patients with gynecological malignancy.

PURPOSE: The aim of the study was to evaluate patient tolerability and compliance to two bowel cleansing agents (PEG-ELS and NaP) as well as to compare the cost effectiveness. METHODS: Three hundred and forty-three consecutive patients were randomized to receive either the standard 4 1 of polyethylene glycol and electrolyte lavage solution (PEG-ELS) or 90 ml of sodium phosphate (NaP). All patients were advised to be on a clear liquid diet one day before starting the bowel cleansing regimen and to take ornidazole orally (3 x 2 tablets) 24 hours before surgery. Patient tolerabilty and compliance to the regimens were assessed based on complaints of nausea, vomiting and the need of antiemetics. In addition completion of the regimens was evaluated in both groups. RESULTS: The need for antiemetics because of nausea and vomiting was statistically higher in the PEG-ELS group than the NaP group (p = 0.000). Regimen completion rate was statistically higher in the NaP group than in the PEG-ELS group (p = 0.000). NaP is more cost effective than PEG-ELS. CONCLUSION: NaP was rated superior to PEG-ELS in terms of patient tolerability, compliance, completion of the regimen and cost effectiveness and should be the first-choice treatment.

A rare case of low-grade endometrial stromal sarcoma with myxoid differentiation and atypical bizarre cells.

Endometrial stromal sarcoma (ESS) is a rare mesenchymal tumor with characteristic histological appearances, consisting of diffuse infiltrate of small uniform endometrial stromal cells with a multinodular arrangement and distinct vascular pattern. Less common variants of ESS include "mixed endometrial stromal and smooth muscle tumors", "endometrial stromal tumors resembling ovarian sex cord tumors" and "endometrial stromal neoplasms with endometrial glands", and "aggressive endometriosis". Rarely do endometrial stromal tumors have a prominent fibrous or myxoid appearance which causes confusion and possible misdiagnosis as myxoid leiomyosarcoma. In this report we present a very unusual subtype of ESS in a 32-year-old woman. The tumor revealed atypical pleomorphic bizarre cells which were stained positive only with vimentin and CD10 in an abundant myxoid matrix. A low-proliferative rate was established with MIB-1 staining. To our knowledge such appearance has not been previously reported.

Role of dietary habits on fetal anomaly development: review of 315 consecutive fetal anomaly cases.

OBJECTIVE: This study aimed to investigate and speculate on the dietary habits and certain environmental factors of the Southeast Anatolia region which are thought to be related with fetal anomaly development. MATERIALS AND METHODS: Patients admitted to Gaziantep University Faculty of Medicine Obstetrics and Gynecology Department with fetal anomalies between January 2003 and June 2007 were evaluated. Three hundred and fifteen patients with intrauterine fetal anomaly were detected. The number of total deliveries during this period were 7,554. Twenty-eight of the patients were above the age of 35. According to the history of patient, mean gravidity was 6.6 (1-13), consanguineous marriage rate was 25%, previous abnormal rate was 15%, and previous missed abortion was 35%. Eighty-eight percent of patients were of low sociocultural status. The frequency of daily dietary habits, especially tea consumption, red chili pepper consumption and eating barbecued meat were questioned with the anamnesis. RESULTS: Total fetal anomaly incidence was found to be 4.17%, neural tube defects 1.37%, renal anomalies 0.54%, non-immune fetal hydrops 0.46%, cystic hygroma 0.39%, central nervous system anomalies 0.36%, chromosomal anomalies 0.17%, gastrointestinal system anomalies 0.147%, sacrococcygeal teratoma 0.12%, cardiac anomalies 0.09%, and respiratory system anomalies 0.049%. Mean daily tea comsumption during pregnancy was 8 cups/day. Mean frequency of eating barbecued meat was 4 times/week. Mean chili pepper consumption was 10 g/day. CONCLUSION: In this study, four times higher overall fetal anomaly incidence appeared to be strongly correlated with Southeast Anatolia region's dietary habits. In the future monitoring women's dietary habits should have an important role in the prevention of fetal anomaly development.

Serum CA-125 is a good predictor of benign disease in patients with postmenopausal ovarian cysts.

AIM: To determine whether serum CA-125 levels, in addition to tumor size and ultrasonographic findings can help in differentiating benign ovarian cysts from malignant disease. METHODS: All postmenopausal women who had undergone explorative laporatomy for a preoperative diagnosis of an adnexal cyst between January 1999 and February 2006 were included if serum CA-125 levels were below 50 IU/ml. RESULTS: Ninety-three patients with ovarian cysts and serum CA-125 levels lower than 50 IU/ml were included. Seventy-five (80%) of the patients (53 unilocular, 22 multilocular) had ovarian cysts < 13 cm. Of 18 patients with ovarian cysts > 13 cm, seven had unilocular and 11 had multilocular cysts. All the patients (n = 77) with a serum CA-125 level < 35 IU/ml had benign histopathology regardless of the tumor size or ultrasonic features. Among 16 patients with CA-125 levels between 35 and 50 IU/ml, two with unilocular cysts > 13 cm and nine with multilocular cysts (3 < 13 cm, 6 > 13 cm) had borderline histopathology. CONCLUSION: We concluded that when unilocular ovarian cyst size is < 13 cm and serum CA-125 levels are below 35 IU/ml in a postmenopausal woman, the possibility of a benign etiology is most likely.

Frontiers of Ovarian Cancer Therapy.

Since the majority of patients with ovarian cancer present with advanced stages of disease, more effective systemic approaches are needed to add to the benefits of surgical staging and debulking. New combinations of taxoids with cisplatin have prolonged survival, and other chemotherapeutic agents are being evaluated. Immunotherapy, including intraperitoneal approaches with monoclonal antibodies, cellular therapies and vaccines, hormone therapy with well-known drugs such as tamoxifen, and gene therapy give promise for the future.

Ultrasound guided aspiration of benign ovarian cysts: an alternative to surgery?

Treatment of ovarian cysts remains a problem for gynecologists despite the different treatment modalities that are available. This prospective study included 19 patients (aged 16-34 years) who were treated with ultrasound guided aspiration; cyst diameter ranged from 6 to 16 cm (mean 8 cm). There were recurrent cysts in five of the 19 patients. The results indicate that in cases of benign ovarian cysts, ultrasound guided aspiration may be an alternative to other treatment modalities.

Paclitaxel/carboplatin versus cyclophosphamide/carboplatin in peritoneal carcinomatosis of the ovary.

The preceding platinum-based combination chemotherapy could possibly reduce tumor masses, allowing for adequate surgical debulking in advanced ovarian cancer. In this study, a total of 18 patients with peritoneal carcinomatosis of the ovary were evaluated between 1996 and 2003. All patients underwent open biopsy for the histopathologic confirmation of ovarian tumor. Forty-one percent of the patients (8/18) were administered six cycles of carboplatin/cyclophosphamide (CP) and the rest were administered six cycles of paclitaxel/carboplatin (TP) as a neoadjuvant chemotherapy (10/18). After six cycles of chemotherapy metastases to the peritoneum, Douglas' pouch, diaphragm, and liver serosa were higher in the CP group than the TP group (p < 0.05). All patients also had a better performance status (WHO performance status 0 or 1), but no statistical difference was observed between either group (p > 0.05). Optimal debulking surgery rates were significantly higher in the TP group (p < 0.05). In conclusion, we suggest paclitaxel/carboplatin in peritoneal carcinomatosis of the ovary as a neoadjuvant chemotherapy. However, large prospective, randomized studies should be performed in patients with peritoneal carcinomatosis of the ovary.

Neoadjuvant chemotherapy in ovarian cancer.

Patients with advanced ovarian cancer have a chance of less than 50% after radical debulking surgery. In spite of the currently more effective combination chemotherapy agents that have become available as adjuvant therapy in the last decade, the prognosis of patients with residual tumor mass larger than 1 cm in diameter following surgery is still poor. Neoadjuvant or primary chemotherapy has been suggested as an alternative approach to primary laparotomy of the bulky ovarian cancer. The advantages and available data on neoadjuvant chemotherapy are discussed in this review.

Complications following combined surgery (radical vulvectomy versus wide local excision) and radiotherapy for the treatment of carcinoma of the vulva: report of 73 patients.

Cancer of the vulva is uncommon, accounting for only 5% of all gynecologic malignancies, and usually occurs in women over 60 years of age. The historic treatment of choice for invasive squamous cell carcinoma of the vulva is radical vulvectomy with bilateral inguinal lymphadenectomy, which has produced excellent long-term survival. We retrospectively analyzed the complications of wide local excision plus postoperative radiotherapy compared with those of radical vulvectomy and bilateral lymphadenectomy plus pre-or postoperative radiotherapy in 73 patients with vulvar cancer. There were no significant differences among these treatments in terms of primary tumor control, 5-year disease-free survival, and overall survival. Based on these results, the best treatment alternative for advanced vulvar cancer is wide local excision plus radiotherapy, as this method retains the high survival of traditional therapy but has less morbidity.

Characteristics of patients with vulvar cancer: an analysis of 94 patients.

Vulvar cancer is uncommon, accounting for 3 to 5% of all female genital cancers. Because this cancer is so rare, not much is known about the characteristics of this patient group. The purpose of this study was to determine these characteristics in a group of 94 women with vulvar cancer. We retrospectively analyzed the condition associated with vulvar cancer in 94 women who were treated with surgery and irradiation or irradiation alone. In these patients, hypertension (found in 40% of patients) was the most prevalent conditions associated with vulvar cancer. Our results confirm those of previous studies; chronic dermatologic diseases, chronic metabolic diseases such as cardiovascular illnesses, hypertension, diabetes, and smoking are the most frequent medical conditions found in this patient group.

Cancer pain, pathophysiology, characteristics and syndromes.

In this study the pathophysiology and characteristics of cancer pain together with cancer pain syndromes and guidelines of management are reviewed. Tumour-associated pain may be nociceptive (somatic or visceral) if the sustaining mechanisms are related to ongoing tissue pathology, or neuropathic when pain is associated with injury to neural tissues. The mechanism by which tumours produce pain include obstruction of lymphatic and vascular channels, distension of a hollow viscous, oedema and tissue inflammation or necrosis. Injury to tissues results in the local release of numerous chemicals that mediate transmission of pain stimulus. Cancer pain syndromes result from one or more of three fundamental causes; direct tumour involvement of tissues, cancer-directed therapy, and mechanisms unrelated to cancer or its treatment. Cancer pain syndromes are also classified as acute or chronic. Cancer pain characteristics provide some of the data essential for syndrome identification. These characteristics include intensity, quality, distribution and temporal relationships. The principles of tumour-directed pain control include modifying the source of pain by treating the cancer and the inflammatory response to cancer, altering the central perception of pain and interfering with nociceptive transmission within the central nervous system.

Intraoperative gold grain implants for pelvic wall recurrences of various malignancies: toxicity, results, and failure analysis in 37 patients.

PURPOSE: We conducted this study to determine the complications and long-term results of intraoperative gold-grain implants as therapy for pelvic wall recurrences of various malignancies. MATERIALS AND METHODS: We retrospectively analyzed complications and long-term results of intraoperative radioactive 198Au gold grain implants of 4-mc radon equivalent in 37 patients with pelvic wall recurrences of various malignancies treated at the University of Texas M. D. Anderson Cancer Center. The estimated dose was 30-100 Gy, which was increased to 100-120 Gy plus external-beam irradiation if the dose to the tumor volume was too low. All patients had follow-up of 4 months to 12 years. Of the 37 patients, 34 had lower leg edema, 22 had lower limb pain, and 22 had ureteral obstruction. RESULTS: Six of 34 patients with lower limb pain had partial relief and nine had complete relief. Of 22 patients with ureteral obstruction, ten had complete resolution and four had partial relief. Lower limb edema was improved in 16 of 22 patients. Of the 37 patients studied, 14 are alive and 23 have died. CONCLUSION: In selected patients, gold grain implantation to a dose of 70-100 Gy relieved some symptoms of unresectable pelvic wall recurrences of various malignancies. We believe that intraoperative gold grain implants appear to be the only useful treatment for patients with recurrent malignancies fixed to the pelvic wall and provide these patients with better and longer palliation and a good quality of life.

Advanced primary carcinoma of the Bartholin gland: report of 18 patients.

Conservative surgery plus radiotherapy for vulvar cancer has been established as a therapeutic alternative to extensive radical surgery and produces a similar cumulative 5-year survival. We retrospectively analyzed the cases of 18 patients with advanced primary carcinoma of the Bartholin gland treated with wide local excision (WLE) or radical vulvectomy and lymphadenectomy followed by radiotherapy (RT) at the University of Texas M. D. Anderson Cancer Center from January 1978 through December 1990. All patients have been observed for a minimum of 7 months (maximum follow-up, 15 years; median follow-up, 9 years). Of the 18 patients, 7 were treated with wide local excision (WLE) followed by radiation therapy (RT) (Group 1), 9 had radical vulvectomy (RV) followed by RT to the vulvar and inguinal-femoral and pelvic node areas (Group II), and 2 were treated with RT alone after biopsy of the tumor (Group III). The 5-year disease-free survival rates were 86%, 78%, and 50% for groups I, II, and III, respectively, and 83% for the whole group. Of 2 patients treated with RT alone, one lived for 6 years with no evidence of disease, and the other lived for 20 months. The rate of local tumor control was 100% for all three treatment groups. There were no significant differences among the treatment groups in rate of primary tumor control or 5-year disease-free survival rate (p=0.1300). The present study demonstrated WLE followed by RT is the best treatment for advanced primary carcinoma of the Bartholin gland. Less radical surgery plus RT produces good long-term survival and has fewer complications.