Acardiac twin pregnancy: successful intrauterine ablative treatment with alcohol at 14 weeks of gestation.

Twin reversed arterial perfusion (TRAP) sequence is a serious condition of monochorionic twin pregnancy, occurring in approximately one in 35,000 cases. First trimester treatment of TRAP sequence is controversial with higher incidence of procedure related complications. Present case demonstrates a TRAP sequence that was managed by intrauterine treatment with one-ml 100% pure alcohol injection into the abdominal part of the umbilical artery and obliteration of the acardiac twin at 14 weeks of gestation. Antenatal follow-up was uneventful and elective cesarean section was performed at 39 weeks' gestation. Postnatal outcome of the pump twin was excellent at 30 months after birth. Early second trimester elective ablation by alcohol injection can be an inexpensive, alternative, and reasonable minimal invasive treatment option to prevent fetal loss of pump twin before mid and late second trimester in perinatology centers where intrafetal cord occlusive methods are not available.

A large pedunculated leiomyoma with two-sided cystic degenerations mimicking a bilateral ovarian malignancy: a case report.

The authors present an unusual case of a large, pedunculated uterine leiomyoma with two-sided cystic degenerations, which mimicked a bilateral malignant ovarian tumor on ultrasonography and magnetic resonance imaging (MRI). A 32-year-old unmarried female patient presented to our outpatient clinic with complaints of abdominal distention and a palpable abdominal mass extending into the upper abdomen. Ultrasonography and MRI revealed a large solid mass with bilateral cystic areas extending into both uterine adnexa. The patient then underwent a laparotomy. Gross examination revealed normal ovaries and a pedunculated mass with two-sided prominent cystic structures originating from the uterine fundus. The tumor was excised through the peduncle and pathologic evaluation revealed a uterine leiomyoma with cystic degenerations. In conclusion, a large, pedunculated leiomyoma with two-sided cystic degenerations can mimic a bilateral malignant ovarian neoplasm on imaging studies. Therefore, uterine leiomyomas with bilateral cystic degenerations should be considered during the differential diagnosis of malignant ovarian masses.

Detection and importance of micrometastases in histologically negative lymph nodes in endometrial carcinoma.

BACKGROUND: Lymph node status is the most important prognostic factor in terms of its relation to long-term survival of endometrial carcinoma (EC) patients. We aimed to investigate the rate of micrometastases in lymph nodes of EC patients that were previously reported as negative with routine histopathology, and the relationship with clinical and pathologic factors. MATERIALS AND METHODS: With immunohistochemistry, we retrospectively looked at cytokeratin staining of lymph nodes from 47 EC patients, that were previously reported to be negative for lymph node metastases after full surgical staging and routine histopathologic investigation. We also looked at the relationship between micrometastases and clinical, histopathologic factors and recurrence. RESULTS: Of all 47 patients, seven (14.9%) were found to have micrometastases in their previously negatively reported lymph nodes. Six out of seven of these patients (85.7%) were high-risk EC patients. Among high-risk EC patients, 50% had micrometastases, whereas only one patient out of 35 with low or intermediate risk had micrometastases (2.9%). The difference between these groups was statistically significant (p = 0.001). Grade was also correlated with micrometastases (p = 0.0001). Mean follow-up time was 55.5 +/- 13.3 months. There were two recurrences in the group having cytokeratin micrometastasis, whereas no patients without micrometastases developed any recurrence. While 36 months recurrence-free survival (RFS) was 100% in patients without micrometastases, it was 71% in patients with micrometastases (mean rate 57 months) (p = 0.0004). Both RFS and overall survival were statistically significantly inferior for patients having micrometastases, high-risk status, and lymphovascular space involvement (p < 0.05). CONCLUSION: It seems reasonable to further analyze negative lymph nodes in high-risk EC patients for micrometastases utilizing immunohistochemistry techniques. Half of this group of patients are still at risk of lymph node metastases even if routine histological findings are negative for metastases. The finding of micrometastases can change therapeutic decisions for the better by incorporating adjuvant treatment options.

Mucinous cystadenoma in a female patient with 45,X/46,XY karyotype.

The mosaic karyotype of 45,X/46,XY has a wide phenotypic spectrum and there are substantial differences between prenatally and postnatally diagnosed cases. The phenotype varies between normal male to classical Turner syndrome. There is a high risk of gonadal tumor development in the dysgenetic gonads of patients with sex chromosome mosaicism. We report a case of a 24-year-old patient with a pelvic mass and amenorrhea referred to our laboratory for karyotyping. Peripheral blood chromosome analysis showed a mosaic karyotype of 45,X[17]/46,XY[83]. The tumor originated from the left ovary and the right ovary was found to be a streak gonad. The uterus was intact. Pathologic examination of the tumor revealed mucinous cystadenoma. Physical examination of the patient showed signs of Turner syndrome, as short stature (145 cm), short neck and asymmetric shoulders. Her mental state was normal. Y chromosome microdeletion screening involving SRY and ZFY genes was performed and no deletion was found. The patient was informed about the condition during the genetic counseling session.

Impact of morbid obesity in surgical management of endometrial cancer: surgical morbidity, clinical and pathological aspects.

OBJECTIVE: To evaluate the effect of body mass index (BMI) on clinical, surgical, pathologic features, and surgical morbidity in the management of patients with endometrial cancer. MATERIALS & METHODS: All endometrial cancer patients who were surgically treated in our institution between January 1, 2003 and January 1, 2006 were eligible for the study. Forty-two out of 60 patients were included in the analysis from our cancer database. The patients were divided into three groups: BMI < 30, BMI 30-40, BMI > 40. Statistical analysis was performed by SPSS for Windows (version 11; SPSS, Inc., Chicago, IL). RESULTS: Lymphadenectomy as part of surgical staging was performed in 90.5% of all patients. Although patients with a BMI > 40 were less likely to have positive lymph vascular space invasion (LVSI) (p = 0.042), chance of deep myometrial invasion and positive lymph nodes (18%) were the same as for patients with a BMI < 30. Patients with a BMI > 40 had statistically longer operating times when compared to patients with a BMI < 40 (p = 0.039). Wound separation rate was statistically higher in the morbidly obese patients (p = 0.01). Average number of lymph nodes removed, hospital days, intraoperative and overall postoperative complication rates did not differ among the three groups (p > 0.05). CONCLUSIONS: This study confirms that comprehensive surgical staging can be performed adequately and safely in obese and morbidly obese endometrial cancer patients with no difference in length of hospital stay, intraoperative or postoperative complications. As a result adjuvant treatment of morbidly obese patients can be planned accordingly preventing under or over treatment.

Gastrointestinal stromal tumors presenting as pelvic masses: report of two cases.

We present two cases of gastrointestinal stromal tumors (GISTs) that presented as pelvic masses. These tumors can present diagnostic problems and they may be difficult to discover preoperatively. GISTs are neoplasms that can be diagnosed utilizing immunohistochemistry, especially detecting CD117 (c-kit) reactivity along with associated histological features. GISTs, should be considered in the differential diagnosis of ovarian tumors especially when imaging studies and rectovaginal examination findings are inconclusive and vague. Histologic diagnosis of these tumors are important considering the efficacy of tyrosine kinase inhibitor therapy after surgery in such cases.

Malignant struma ovarii: a case report.

Malignant struma ovarii is a rare form of the ovarian germ cell tumors. Hence, diagnosis and management of malignant struma ovarii have not been clearly defined. We present the case of a 34-year-old woman with papillary carcinoma arising in struma ovarii. The malignant component of this tumor was detected after laparoscopic removal, and a re-staging operation was performed afterwards. There was no evidence of clinical malignancy or metastases. In this paper, clinical features, treatment guidelines, diagnostic features, and immunohistochemical characteristics of this tumor are reviewed.

HPV and p53 expression in epithelial ovarian carcinoma.

OBJECTIVES: Human papillomavirus is the causal factor for cervical cancer. However, the role of HPV infection in ovarian cancer is unclear. This study aimed to determine the presence of human papillomavirus (HPV) in ovarian cancer tissues along with the expression of tumor suppressor gene p53. We also investigated any possible association of HPV with p53 gene mutations in ovarian carcinoma. METHODS: Archived human ovarian cancer tissues (n = 40 cases of epithelial ovarian cancer) embedded in paraffin blocks were used. Controls were 32 non-malignant ovarian tumor tissue blocks. In situ hybridization (ISH) and immunohistochemistry (IHC) were used to detect the presence of HPV and p53 expression, respectively. RESULTS: Of the total, 37.5% (n = 15) of malignant and 28.1% (n = 9) of benign ovarian tumors were positive for HPV (OR: 1.5 CI: 0.5-4.1, p = 0.4). The difference was not statistically significant. However, p53 was detected in 72.5% (n = 29) of malignant cases compared to 37.5% (n = 12) of benign cases (OR: 4.3 CI: 1.6-11.9, p = 0.003). Furthermore, a positive correlation between HPV and p53 expressions in ovarian cancer tissue samples was detected (r = 0.47, p = 0.001). CONCLUSIONS: HPV does not seem to be a major component in the development of ovarian carcinoma, nevertheless HPV positivity seems to contribute to the pathogenesis in at least some ovarian carcinoma cases by way of interaction with tumor suppressor p53.

Primary ovarian leiomyosarcoma: a case report.

Primary ovarian leiomyosarcomas are extremely rare tumors that comprise less than 0.1% of all ovarian malignancies. We present a case of 62-year-old postmenopausal woman with a slightly enlarged right ovary and a Color Doppler sonography resistance index (RI) measuring 0.54. The patient, after being managed with surgery alone, is alive after 14 months without any evidence of disease. This is an unusual case in that primary ovarian leiomyosarcoma was diagnosed in the setting of a slightly enlarged irregular postmenopausal ovary with a concomitant intermediate RI value on color flow Doppler evaluation. A high index of suspicion may help prevent delay in the diagnosis of this rare neoplasm.

BCL-2 and P53 expression in endometrial carcinoma.

Our aim was to compare the results of bcl-2 expression in endometrial carcinoma with clinicopathological prognostic factors along with p53 accumulation. In addition, p53 expression was compared to different subtypes of endometrial carcinoma. Immunohistochemical staining was performed on formalin-fixed, paraffin embedded tissue sections by using Bcl-2 Supersensitive Mouse Anti-Bcl-2 Oncoprotein (Biogenex AM287-5M) for bcl-2 immunostaining and Supersensitive Mouse Anti-p53 Suppressor Gene Product (1801) (Biogenex AM 240-5M) for p53 immunostaining. 9 out of 9 cases of proliferative endometrium, 5/5 cases of endometrial hyperplasia without atypia, 5/5 cases with atypia, and 21/35 cases of endometrial carcinoma showed bcl-2 protein expression. Bcl-2 expression was not related to age, surgical stage, or histopathological features, nor was there an inverse correlation between bcl-2 and p53 expression in endometrial carcinoma. p53 expression was detected in 3/4 cases of serous papillary carcinoma, whereas only 5/31 cases of endometrioid carcinoma showed p53 expression. Bcl-2 expression decreased in endometrial carcinomas, and mechanisms other than p53 may play a role in the regulation of bcl-2 expression in endometrial carcinoma. Abnormal p53 protein expression is an important event in the development of serous tumors, which may explain partly why they are more aggressive than their endometrioid counterparts where p53 expression does not play a major role.

Management of advanced-stage primary carcinoma of the fallopian tube: case report and literature review.

Primary carcinoma of the fallopian tube is a very unusual gynecologic malignancy that accounts for less than 1% of all malignancies of the female genitalia. A 55-year-old, gravida 7, para 3 woman presented with no gynecologic complaints other than backache. TVS demonstrated a 35 x 25 mm heterogeneous mass that was not clearly separated from the left ovary, and another 31 x 14 mm cystic septated lesion in the left ovary region. Pelvic MRI demonstrated a 35 x 35 x 20 mm left adnexal mass that enhanced with contrast and a neighboring tubular-cystic mass. Upper and lower gastrointestinal endoscopy revealed no malignancy. Serum CA 125-level was merkedly elevated at 369 U/ml (normal < 35 U/ml). Laparotomy revealed left hydrosalpinx and a papillary-fimbrial mass. Pelvic lymph node metastases were observed. Frozen-section analysis identified the mass as a serous adenocarcinoma. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, pelvic and para-aortic lymph node dissection, and peritoneal washing were performed. The definitive histopathological diagnosis was primary serous adenocarcinoma of the fallopian tube with six of 25 lymph node biopsies showing metastasis. Six cycles of paclitaxel (175 mg/m2) plus cisplatin (75 mg/m2) combinatin chemotherapy were administered with 3-week intervals between cycles. Second-look laparotomy was performed; there was no evidence of disease. At the time of writing 12 months after the second-look laparotomy, she was still disease-free.

Well-differentiated papillary mesothelioma complicating endometrial carcinoma: a case report.

We present a case of well-differentiated papillary mesothelioma discovered during staging surgery for endometrial carcinoma in a 50-year-old postmenopausal woman. In case of simultaneous well-differentiated papillary mesothelioma (WDPM) and endometrial carcinoma, the surgeon may be mistaken by considering peritoneal implants as tumor metastasis. This situation may result in overtreatment of the patient. Thus a thorough pathologic examination of the specimens taking care not to miss any areas of invasion, and utilizing immunohistochemical analysis when necessary are important to avoid such mistakes. To our knowledge this is the first report of the simultaneous occurrence of endometrial carcinoma in conjunction with diffuse WDPM of the peritoneum.

Expression of cyclin H in normal and cancerous endometrium, its correlation with other cyclins, and association with clinicopathologic parameters.

Cyclins are known as regulatory proteins in cell cycle. Cyclin H is a part of cyclin H/Cdk7/Mat1 complex, which is necessary for cellular proliferation. This study was designed to investigate the correlation of cyclin H expression with tumorigenesis of the endometrium and clinicopathologic variables. Immunohistochemical staining using labeled streptavidin-biotin complex was performed on formalin-fixed, paraffin-embedded endometrial tissues of the proliferative, hyperplastic, and carcinomatous types. Immunostaining for cyclins A, B1, D1, D3, E, H, and cyclin dependent kinase 2 were evaluated. The expression of cyclins A, D1, D3, and H in hyperplasia was significantly more frequent than those of proliferative phase and less than those of endometrioid adenocarcinoma. The expression of cyclin H was correlated with lymphvascular space invasion and clinical stage in carcinoma but not with myometrial invasion, lymph node metastasis, and menopause status. The expression of cyclin H could be involved in the transformation of the endometrium into malignancy and might be a marker for more proliferative and malignant features. It might be one of the biomarkers for determining proliferative activity in endometrial hyperplasia and endometrioid adenocarcinoma.

Expression of survivin, PTEN and p27 in normal, hyperplastic, and carcinomatous endometrium.

We aimed to investigate if expressions of survivin and p27 proteins are involved in the development of endometrioid carcinoma, along with whether there are any correlations between these proteins and loss of wild-type PTEN that is found in up to 80% of endometrial carcinomas. We also studied their correlations with classical prognostic factors and survival in endometrial carcinoma. To our knowledge, this is the first time survivin expression is investigated in endometrial hyperplasia along with endometrioid adenocarcinoma. For immunohistochemical analysis, 29 endometrioid adenocarcinoma, 38 endometrial hyperplasia, and 10 proliferative endometrium tissue samples were selected in the pathology archives. Staining of cells was scored as +2 if >50%, +1 if <50%, and negative if none were stained positive. Survivin expression increased from proliferative to hyperplasia to carcinoma cases. PTEN and p27 expressions decreased in hyperplasia and carcinoma cases with respect to proliferative endometrium. All these differences were statistically significant (P < 0.05). PTEN positively correlated to p27 (P < 0.05); however, neither was correlated with survivin. None of these genes were correlated with classical prognostic factors such as grade and myometrial invasion in endometrioid adenocarcinoma. However, mean survival was statistically significantly higher in PTEN-positive cases (46.6 vs 16.4 months) (P < 0.05). Survivin overexpression might be one of the important mechanisms in the development of endometrioid adenocarcinoma along with lost or decreased activity of PTEN and p27. However, survivin seems to exert its role in ways different from those of PTEN or p27 in the development of endometrioid adenocarcinoma. These findings on the role of survivin in endometrioid adenocarcinoma should be confirmed and the pathways through which survivin acts in endometrioid adenocarcinoma studied further with a larger sample size.