An unusual case of mammary gland-like carcinoma of vulva: case report and review of literature.

INTRODUCTION: Accessory breast tissue is a very rare finding in the general population with an incidence of one to two percent. An even rarer occurrence is accessory mammary-like tissue which developed breast carcinoma. The authors present a case of aggressive and metastatic carcinoma of vulvar originating from mammary-like tissue. CASE: A 73-year-old Caucasian female presented with a lesion in her left vulva. The lesion was ulcerated and fragile. A dermatologist had evaluated the lesion and took a punch biopsy. Result was vulvar carcinoma. She was admitted to the gynecologic oncology clinic then after and was operated. After a radical vulvectomy and bilateral inguinal lymphadenectomy she received adjuvant radiotherapy because of lymph node metastasis. One year after the finish of radiotherapy patient was found to have lung and femur metastasis. She began to receive systemic chemotherapy for metastasis. CONCLUSION: Primary mammary-like adenocarcinoma of the vulva is exceedingly rare. There is no consensus about the diagnosis, treatment, and follow up of these patients in literature. However, given that histological data confirms these cancers are behaving like breast cancers instead of known patterns of vulva cancer, the best treatment practices for breast cancer may be applied to treat these vulvar carcinoma patients.

Intrauterine endometriotic cyst at the site of previous cesarean scar; scar endometriosis.

Uterine scar endometriosis is an extremely rare entitiy. As the surgical procedures of the uterus increases through time, scar endometriosis may be diagnosed more often in the future. A case of uterine scar endometriosis is presented with complaints of menstruation lasting one day with associated pelvic pain. When a cystic mass in the site of previous surgery is diagnosed, scar endometriosis must be considered.

Non-invasive prenatal diagnosis of fetal RhD by using free fetal DNA.

OBJECTIVE: Anti-D immunoglobulin is applied to all pregnant women having RhD incompatibility to prevent hemolytic disease of the newborn. The aim of this study is to determine fetal RhD status in the Rh incompatible pregnancies with an non-invasive technique; free fetal DNA isolation from maternal circulation. In the case of Rh incompatibility especially with a history of previous fetal anemia, it can be beneficial to know Rh status antenatally in terms of monitoring fetuses with Rh positive [RhD(+)] status consciously. MATERIALS AND METHODS: Total free DNA was isolated in 50 Rh negative [RhD(-)] pregnant women, who had RhD alloimmunisation with their husbands. The gene in isolated DNA was investigated with TagMan prob and real time PCR by using primers belonging to exon 7 of the RhD gene. RESULTS: The authors analyzed 50 RhD(-) women by using quantitative real time PCR technique. Five of them were RhD(-) and the rest of them were found to be RhD(+). After birth one of the infants who were analyzed as RhD(+) were found to be RhD(-). CONCLUSION: The detection of fetal RhD status by using a non-invasive method from maternal circulation was found to be possible. Assessing fetal RhD status non-invasively by using free fetal DNA in maternal blood will be cost-efficient, avoiding unnecessary indirect Coombs test and unnecessary Rhogam applications that is used in RH incompatible pregnancies. This study will throw a fresh light on prenatal diagnosis.

Serum visfatin levels do not increase in post-menopausal women with metabolic syndrome.

BACKGROUND: The aim of this study was to determine the serum visfatin levels in post-menopausal (PM) women with and without metabolic syndrome (MS) and to understand the correlation between serum visfatin levels and various other hormonal and metabolic parameters. MATERIALS-METHODS: We conducted a prospective cross-sectional study including 17 PM women with MS and a control group of 51 PM women without MS. MS was defined according to the National Cholesterol Education Program Adult Treatment Panel III. RESULTS: Women with MS had statistically significantly higher fasting blood glucose, HDL, triglycerides, insulin, homeostasis model assessment of insulin resistance, and SHBG levels when compared to women without MS. Estradiol, high sensitivity C-reactive protein, and free testosterone levels were higher in the MS group, but there was no statistically significant difference between the two groups. Visfatin levels did not differ between the two groups. There was no correlation between serum visfatin levels and other parameters. CONCLUSIONS: There was no association between serum visfatin levels and MS in PM women.

Retinol-binding protein 4 is elevated and is associated with free testosterone and TSH in postmenopausal women.

The aim of this study was to understand the relationship of retinol-binding protein 4 (RBP4) with hormonal and biochemical parameters in pre- and postmenopausal women. We included 69 postmenopausal women and 27 regularly menstruating premenopausal women. Postmenopausal women had statistically significantly higher RBP4 levels when compared to premenopausal women. RBP4 levels were negatively associated with free testosterone and positively associated with thyroid stimulating hormone in postmenopausal women. In premenopausal women RBP4 was positively associated with body mass index. RBP4 levels were increased in postmenopausal women. Although the mechanism is not clear, these findings suggest that RBP4 has a role in the regulation of hormonal and metabolic parameters.

Can quadruple test parameters predict SGA infants?

The aim of this study was to investigate the role of quadruple test parameters in predicting the risk of delivering a small for gestational age (SGA) infant. The quadruple test results of patients performed at 16-18 weeks of pregnancy were searched retrospectively. Alpha-fetoprotein (AFP) levels higher than 2 MoM were associated with a risk of delivering an SGA infant (p = 0.025), sensitivity 8%, specificity 98%, positive predictive value 25%, negative predictive value 91%. Other quadruple test parameters were not related to delivery of an SGA infant. The introduction of AFP as a screening test for the detection of SGA infants does not seem feasible, but we suggest clinicians take it into account when counselling the patients about the results of Down syndrome screening tests.

Primary mucinous borderline tumor of the vermiform appendix mimicking ovarian carcinoma; case report.

INTRODUCTION: Primary adenocarcinoma of the vermiform appendix is a very rare entity. Borderline mucinous tumor of the appendix is a much more rare disease. CASE: We present a 71-year-old woman with primary mucinous borderline tumor of the vermiform appendix. She was misdiagnosed as an ovarian carcinoma patient and operated on by a gynecologic oncology team. Her frozen section analysis of an appendicial mass resulted as borderline tumor of appendix vermiformis, and right hemicolectomy, as is advised in invasive colon tumors, was not carried out. CONCLUSION: Borderline mucinous tumor of the appendix vermiformis should be kept in mind in patients who have pseudomyxoma peritonei during surgery. Tumoral resection may be the definitive therapy in these patients.

Malignant primary peritoneal mesothelioma: report of two cases and review of literature.

INTRODUCTION: Malignant primary peritoneal mesothelioma is a rare and highly aggressive tumor. This tumor can be misdiagnosed as ovarian carcinoma. CASE: Two cases of malignant primary peritoneal mesothelioma that were misdiagnosed as ovarian carcinoma were operated in our instutition. Patients were 74 and 45 years-old at admittance. CONCLUSION: Malignant primary peritoneal mesothelioma is being a problem for gynecologic oncologists because of the close similarity with epithelial ovarian cancer. Diagnosis and treatment of these patients are still under debate.

Clinical importance of detection of bacterial vaginosis, trichomonas vaginalis, candida albicans and actinomyces in Papanicolaou smears.

OBJECTIVE: The aim of this study was to determine the role of Papanicolaou (pap) smears in the diagnosis of lower genital tract infections. MATERIALS AND METHODS: A retrospective study was planned by reviewing charts of patients for trichomonas vaginalis, bacterial vaginosis, actinomyces, candida and nonspecific vaginitis. RESULTS: Charts of 9,080 patients were reviewed and 1,733 women had a diagnosis of lower genital tract infection in the pap smear or had had a clinically treated lower genital tract infection. Only 33.5%, 30.4%, 43.3%, and 0% of patients with bacterial vaginosis, trichomonas vaginalis, candida and actinomyces, respectively on pap smear were diagnosed and treated clinically. Postmenopausal patients had a higher rate of trichomonas vaginalis infection and a lower rate of candida infection when compared to women of the reproductive age group. Patients using an intrauterine device for contraception had a statistically significantly increased rate of trichomonas vaginalis and candida infection when compared to women using other contraceptive methods or those who were not using any contraception. CONCLUSIONS: Finding trichomonas vaginalis, bacterial vaginosis and actinomyces infections in pap smears might be considered an indication for treatment without performing other diagnostic tests. Treatment of asymptomatic infections can prevent complications in selected patients. Candida can be a commensal bacteria in the vagina, therefore asymptomatic patients may not require treatment. Detection of a higher rate of trichomonas vaginalis and candida infection in IUD users shows that IUDs can increase the risk of vaginal infections and associated complications.

PCNA and Ki-67 in endometrial hyperplasias and evaluation of the potential of malignancy.

OBJECTIVE: The aim of this study was to investigate malignancy potential in endometrial hyperplasias and association with PCNA and Ki-67. METHODS: Hysterectomy or probe curettage materials of 62 patients (20 simple hyperplasias (SH), six SH with atypical changes, five complex hyperplasias (CH), 11 CH with atypical changes, ten proliferative endometrium (PE) and ten secretory endometrium) were included in our study. Immunohistochemical staining for PCNA and Ki-67 protein was performed on formalinfixed and paraffin-embedded tissue samples. RESULTS: Immunoreactivity of PCNA was found to be significantly higher in atypical CH as compared to all other groups (p < 0.05). Also immunoreactivity of PCNA was significantly lower in SH as compared to atypical CH, and PE (p < 0.05). Average values showed that Ki-67 immunoreactivity is highest for atypical CH, and PE. Immunoreactivity of Ki-67 was found to be significantly higher in atypical CH as compared to other groups except PE (p < 0.05). CONCLUSION: PCNA immunoreactivity can be useful in patients with endometrial CH showing mild or moderate atypical changes in terms of prefering more conservative treatment modalities in those with low PCNA index. Also we suggest that Ki-67 could be insufficient to determine the potential of malignancy.

Lobular carcinoma of the breast metastasizing to leiomyoma in a patient under letrozole treatment.

Metastasis of extragenital neoplasms to the uterus is extremely rare. Lobular breast cancers metastasize to the uterus more than ductal carcinomas, but they metastasize as tiny nodules that can be missed with the standard diagnostic workup. Uterine involvement by a metastatic tumor is usually a manifestation of end-stage disease; patients are reported to die within weeks to months. Therefore surgery is not recommended. Here we report a case of lobular breast cancer metastasizing to a leiomyoma in a patient using letrozole. Our patient was submitted to surgery because the leiomyoma had grown to the level of the xiphoid process. She is alive one year after the operation. In conclusion growth of leiomyomas under aromatase inhibitors should be considered as a sign of metastases and surgery can be planned in selected cases.

Borderline micropapillary serous tumor of the ovary detected during a cesarean section due to a transabdominal cervico-isthmic cerclage in a patient with congenital cervical hypoplasia: a rare case.

A young woman with polycystic ovary syndrome and congenital cervical hypoplasia conceived with clomifen citrate treatment after placement of a transabdominal cervico-isthmic cerclage. Her pregnancy successfully reached term and cesarean section was performed to preserve the cerclage for the next pregnancy; when the ovaries were explored an irregular structure was detected on the left ovary. A wedge biopsy was done and the pathological assessment of the specimen was borderline micropapillary serous tumor of the ovary. The patient wanted to preserve her fertility, therefore a fertility-sparing staging surgery was performed six months after the cesarean section. There was no residual tumor in the left ovary, but there was a borderline tumor in the right ovarian biopsy specimen (frozen section was negative). Two months after staging surgery the patient conceived with IVF and delivered twins at the 33rd week of pregnancy with cesarean section. At her second cesarean section the right ovary and abdomen appeared normal on inspection, but the cerclage tape was in the endocervical canal and was thus removed. To our knowledge this is the second reported case of transabdominal cerclage tape migration into the endocervical canal. The patient is clinically disease-free 18 months after her second cesarean section. The clinical findings, treatment modalities, management and prognosis are discussed together with a literature review of a patient with a serous borderline ovarian tumor and congenital cervical hypoplasia.

Preliminary experience with salvage weekly paclitaxel in women with advanced recurrent ovarian carcinoma.

PURPOSE OF INVESTIGATION: To assess the role of palliative chemotherapy with weekly paclitaxel in patients with recurrent ovarian cancer. METHODS: Thirty-two patients with paclitaxel- and platinum-resistant ovarian cancer were treated with weekly paclitaxel at 80 mg/m2 as a 1-hour intravenous infusion weekly for six weeks every eight weeks (1 cycle). This schedule was considered to be given for three cycles. Evaluation of radiographically measurable disease was used in the assessment of response. CA-125 was used to classify responses only in the absence of a measurable lesion. RESULTS: Thirty-two patients were all assessable for response. Of these, nine patients (28.1%) achieved a partial response and one patient achieved a complete response, leading to an overall response rate of 31.2%. Stable disease occurred in six patients (18.8%), and 16 patients (50%) had progressive disease. Nine patients died of progressive disease while on treatment. The median survival for the entire group was 10.5 months (range 2.5-22 months). Grade 3 or 4 leukopenia and neutropenia occurred in eight and six patients, respectively. Four of these patients developed febrile neutropenia without infection. Grade 1 and 2 peripheral neuropathies were observed in 50% of the patients without causing any premature drop out. Severe (grade 3 or 4) peripheral neuropathy was not observed. There were 11 patients with grade 1 or 2 myalgias. CONCLUSION: Weekly paclitaxel regimen is well tolerated with acceptable toxicity. The favorable toxicity profile and the encouraging antitumor activity observed in this study makes this regimen an option for the salvage treatment of patients with recurrent ovarian cancer.

Prognostic significance of apoptotic index and bcl-2 and p53 expression in epithelial ovarian carcinoma.

PURPOSE OF THE STUDY: To determine if bcl-2 and p53 expression, and apoptotic index (AI) were associated with patient outcome in epithelial carcinomas of the ovary (EOC) and therefore useful as prognostic factors to predict survival. METHODS: A total of 50 women with epithelial carcinomas of the ovary were retrospectively analyzed. The archival paraffin-embedded material of of these cases were evaluated for expression of p53 and bcl-2 by immunohistochemical techniques. Apoptotic cells were detected with an in situ hybridisation method. RESULTS: A total of 33 (66%) of 50 cases showed positive immunoreactivity for the p53 antibody. Twenty-four of the 50 cases showed positive bcl-2 protein expression. Median value for AI was found to be 2.48. No statistically significant association was found between bcl-2 and p53 expression and clinicopathologic features. Univariate survival analysis of AI failed to reveal any effect on prognosis in the study population. CONCLUSION: We found neither p53 nor bcl-2 immunoreactivity to be of prognostic significance in patients with EOC. In addition, AI was not found to be an independent prognostic factor.

Comparison of the effects of atorvastatin and simvastatin in women with polycystic ovary syndrome: A prospective, randomized study.

UNLABELLED: Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism, insulin resistance (IR), and chronic inflammation. Simvastatin improves endocrine/clinical aspects of PCOS and decreases systemic inflammation in PCOS. There have been no comparative studies carried out regarding the effects of different statin treatment in PCOS. We aimed to assess the effects of two different statin treatments on various metabolic, endocrine, oxidative and inflammatory factors in PCOS. DESIGN: Prospective, randomized clinical trial METHODS: Sixty-four (64) women with PCOS were included in the study. Group 1 had (atorvastatin, 20lmg daily; n=32) or group 2 had (simvastatin, 20l mg daily n=32). The metabolic, endocrine, inflammatory and oxidative profiles were evaluated. RESULTS: Group 1 resulted in a significant reduction in the HOMA index and fasting insulin (-26.9+/-9.6%, -26.2+/-10.8%, P<0.01, respectively).CRP levels decreased by 63.6+/-15.9% in group 1 (P<0.01), whereas in the group 2 it decreased by 34.6+/-10.7% (P<0.05). Serum levels of LH declined by 19.1+/-4.5% (P<0.05) in the group 1 and by 39.3+/-11.9% (P<0.01) in the group 2. FAI decreased by -20+/-9.9% in group 1 (P<0.05) and it decreased by -38.7+/-13.8% in the group 2 (P<0.01). MDA levels decreased by 32.6+/-9.6% in group 1 (P<0.05), whereas in the group 2 it decreased by 30.3+/-10.9% (P<0.01). HOMA index and fasting insulin showed a reduction but not reached statistically significance in the group 2 (8.3+/-1.9%, 3.0+/-0.8%, P>0.05, respectively). CONCLUSION: Both the statins are effective in reducing inflammation, hyperandrogenemia, oxidative stress and metabolic parameters. While atorvastatin has more noticeable effects on fasting insulin and insulin sensitivity, simvastatin has a dominant effect on total T in PCOS women.

Prognostic value of p53 accumulation in epithelial ovarian carcinomas.

AIM: To evaluate the prognostic significance of p53 expression in epithelial ovarian carcinomas (EOC), and to look for correlations between p53 and other disease parameters. MATERIAL AND METHODS: Immunohistochemical techniques were used to evaluate p53 expression in paraffin-embedded tissue specimens of 50 EOC cases. RESULTS: p53 immunoreactivity was present in 33 of the 50 cases (66%). The expression of the p53 did not show any association with the tumor histologic type, grade or with the disease stage. However, p53 accumulation was significantly more prevalent among tumors with high mitotic index ( p<0.01). Although median survival was low in the p53 negative cases, this biologic marker did not reveal as an independent prognostic factor in Cox's regression analysis. CONCLUSION: Abnormalities of p53 expression which is an inducer of apoptosis occur commonly in EOC. Although we could not find it as an independent prognostic factor, p53 expression should be studied in larger series to reveal its accurate prognostic significance.