A Rare Case of Primary Vulval Amelanotic Melanoma Involving the Urethra.

A 60-year-old woman came to the Emergency Department complaining of a vaginal formation. The urologist suspected a urethral caruncle: the patient was discharged with vaginal oestrogen cream to relieve symptoms and a follow-up was suggested. After two months the patient returned to the Emergency Department since the mass was increasing in volume and complaining of dysuria and haematuria. Ultrasound, contrast-enhanced computed tomography, and contrast-enhanced magnetic resonance revealed a mass arising from the mucosa and involving the vulva and the urethra, suspicious of malignancy. We present a challenging diagnosis of an infiltrative and rapidly progressive primary vulval amelanotic melanoma with a complete imaging evaluation and a confirmed histological diagnosis.

Stage 1 embryonal rhabdomyosarcoma of the female genital tract: a retrospective clinical study of nine cases.

BACKGROUND: The aim of the study is to investigate the clinical features, treatments, and prognosis of stage 1 embryonal rhabdomyosarcoma of the female genital tract. METHODS: A retrospective analysis was performed on nine cases of stage 1 embryonal rhabdomyosarcoma of the female genital tract. Clinical characteristics, treatments, recurrence, and prognosis were analyzed. RESULTS: Of the nine patients with embryonal rhabdomyosarcoma, three originated from the vagina and six from the cervix. For the eight patients who initially received surgery, the median survival time was 88 months. As for the six patients that received adjuvant chemotherapy, five of them who received six or more cycles of treatment achieved tumor-free survival and the survival time ranged from 9 to 228 months. The remaining patient, who declined further treatment after two cycles of chemotherapy, relapsed 11 months following the surgery and died 3 months later. Out of the nine patients, only one was initially treated with chemotherapy, and achieved complete remission, but relapsed 21 months later. After a combination of surgery and chemotherapy, this patient remained tumor-free for total of 117 months. CONCLUSIONS: Patients with early stage embryonal rhabdomyosarcoma of the female genital tract have good prognosis, and the combination of surgery and chemotherapy can lead to better outcomes.

Predisposing factors for postoperative nausea and vomiting in gynecologic tumor patients.

PURPOSE: To evaluate the predictors of postoperative nausea and vomiting (PONV) in women with gynecologic tumor. METHODS: The analysis was based on prospectively collected data of 82 adult patients with gynecologic tumor, who were submitted to open surgical treatment and undergoing general anesthesia. The predictors included were age ≥50 years, non-smoker, use of postoperative opioids, mechanical bowel preparation, intraoperative intravenous hydration (IH) ≥10 mL/kg/h, and IH in the immediate postoperative, first and second postoperative days (PO1 and PO2) ≥30 mL/kg. A score with predictor variables was built. A multiple logistic regression was fitted. To estimate the discriminating power of the chosen model, a receiver operating characteristic (ROC) curve was plotted and the area under the ROC curve (AUC) was calculated. Statistical significance was set at p value <0.05 and the confidence interval at 95 %. RESULTS: The incidence (%) of nausea, vomiting and both, in the general population, was 36.6, 28.1, 22.0, respectively. The highest incidences of PONV were found in non-smokers and in patients who received >30 mL/kg of IH in the PO2. The results of the adjusted model showed an increased risk of PONV for each 1-point increase in the score punctuation. The relative risk was higher than 2.0 for vomiting in all period and in the PO1. The ROC curve showed great discrimination of postoperative nausea and vomiting from the proposed score (AUC >0.75). CONCLUSIONS: The study population was at high risk of PONV. Therefore, institutional guidelines abolishing modificable variables following temporal evaluation of the effectiveness should be undertaken.

Supplementation with NAD+ and its precursors: A rescue of female reproductive diseases.

Nicotinamide adenine dinucleotide (NAD+) is an essential coenzyme involved in many pathophysiological processes. Supplementation with NAD+ and its precursors has been demonstrated as an emerging therapeutic strategy for the diseases. NAD+ also plays an important role in the reproductive system. Here, we summarize the function of NAD+ in various reproductive diseases and review the application of NAD+ and its precursors in the preservation of reproductive capacity and the prevention of embryonic malformations. It is shown that NAD+ shows good promise as a therapeutic approach for saving reproductive capacity.

Da Vinci SP Single-Port Robotic Surgery in Gynecologic Tumors: Single Surgeon's Initial Experience with 100 Cases.

PURPOSE: To report preliminary experience of single-port robotic surgery using the da Vinci SP surgical system in gynecologic tumors. MATERIALS AND METHODS: This was a retrospective study on 100 consecutive patients who underwent da Vinci SP single-port robotic surgery between November 2018 and January 2021. All procedures were performed by an experienced gynecologic surgeon using a single 2.5-cm umbilical incision. RESULTS: Of the 100 cases, the procedures included myomectomy (n=76), hysterectomy (n=2), endometrial cancer surgical staging (n=14), radical hysterectomy (n=3), radical trachelectomy (n=3), and ovarian cystectomy (n=2). None of the cases was converted to robotic multiport or open surgery. The median docking time was 5.0 minutes [interquartile range (IQR), 3.0-7.0], the median console time was 107.5 minutes (IQR, 78.7-155.8), and the median total operation time was 250.0 minutes (IQR, 215.0-310.0). The median estimated blood loss was 50.0 mL (IQR, 30.0-100.0), and the median change in hemoglobin level was 0.8 g/dL (IQR, 0.3-1.3). The median pain scores rated on a numerical rating scale immediately after and at 6, 12, and 24 hours after surgery were 5, 2, 2, and 2, respectively. The mean duration of postoperative hospitalization was 2.8 days. CONCLUSION: Da Vinci SP single-port robotic surgery was successfully performed in various gynecologic tumors without significant complications. Therefore, this surgical system could be applied in patients who want precise gynecologic surgery while minimizing surgical incision.

Aidi injection, a traditional Chinese biomedical preparation for gynecologic tumors: a systematic review and PRISMA-compliant meta-analysis.

Aidi injection (ADI), a traditional Chinese biomedical preparation, is a promising adjuvant therapy for gynecologic tumors (GTs), including cervical cancer (CC), endometrial cancer (EC), and ovarian cancer (OC). Although studies have reported positively on ADI therapy, its exact effects and safety in GT patients remain controversial. Therefore, a wide-ranging systematic search of electronic databases was performed for this meta-analysis. Data from 38 trials including 3309 GT patients were analyzed. The results indicated that the combination of conventional treatment and ADI markedly improved the patients' overall response rate (P<0.00001), disease control rate (P<0.00001), and quality of life (P<0.05) compared with conventional treatment alone. Furthermore, patient immunity was enhanced with combined treatment, as indicated by significantly increased percentages of CD3+ (P=0.005) and CD4+ (P<0.00001) and increased CD4+/CD8+ ratio (P=0.001). Most of the adverse events caused by radiochemotherapy such as gastrointestinal issues, leukopenia, thrombocytopenia, and hepatotoxicity, (P<0.05 for all) were significantly alleviated when ADI was used in the GT patients. However, other adverse events such as nephrotoxicity, diarrhea, alopecia, and neurotoxicity did not significantly differ between the two groups. Overall, these results suggest that the combination of conventional and ADI treatment is more effective than conventional treatment alone.

Impact of diabetes on gastrointestinal and urinary toxicity after radiotherapy for gynecologic malignancy.

OBJECTIVE: Although diabetes is a common co-morbidity in patients with gynecologic cancer, information about its impact on radiation toxicity in patients with gynecologic cancer treated with external pelvic irradiation is scarce. We aimed to investigate the relation of diabetes with acute toxicity in patients with gynecologic tumors who underwent pelvic +/- paraaortic radiotherapy. MATERIALS AND METHODS: One hundred twenty-nine patients with endometrium or cervix carcinoma were enrolled in the study. Demographic features, presence of diabetes, incidence and severity of upper gastrointestinal (UGIS), lower gastrointestinal (LGIS), and urinary symptoms were recorded from files. Correlation and logistic regression analysis was used to determine the impact of diabetes, age, chemotherapy, paraaortic irradiation on toxicities, and a prediction model was developed. RESULTS: The median age of 77 patients with endometrium cancer and 52 cervix cancer was 61 (range, 25-92) years, and 28 (21.7%) of them had diabetes. The median pelvic and tumor/tumor bed dose was 5040+247.65 cGy and 5040+222.91 cGy, respectively. Age and Gr 0 UGIS toxicity were significantly related (p=0.047). LGIS Gr 0 toxicity was found to be significantly higher in patients with diabetes (p=0.045). Gr 0 and 2 UGIS toxicities were both found to be significantly correlated with paraaortic irradiation (both p<0.001). Diabetes is also an important determinant on UGIS toxicity in patients who underwent paraaortic irradiation. CONCLUSION: The correlation we found between toxicity and diabetes, concurrent chemotherapy or paraaortic radiation necessitates special care and risk stratification for patients with diabetes. Further prospective studies with long follow-up and larger patient groups are warranted.

Cost in perspective: direct assessment of American market acceptability of Co-60 in gynecologic high-dose-rate brachytherapy and contrast with experience abroad.

PURPOSE: While Ir-192 remains the mainstay isotope for gynecologic high-dose-rate (HDR) brachytherapy in the U.S., Co-60 is used abroad. Co-60 has a longer half-life than Ir-192, which may lead to long-term cost savings; however, its higher energy requires greater shielding. This study analyzes Co-60 acceptability based on a one-time expense of additional shielding and reports the financial experience of Co-60 in Peru's National Cancer Institute, which uses both isotopes. MATERIAL AND METHODS: A nationwide survey was undertaken assessing physician knowledge of Co-60 and willingness-to-pay (WTP) for additional shielding, assuming a source more cost-effective than Ir-192 was available. With 440 respondents, 280 clinicians were decision-makers and provided WTPs, with results previously reported. After completing a shielding report, we estimated costs for shielding expansion, noting acceptability to decision makers' WTP. Using activity-based costing, we note the Peruvian fiscal experience. RESULTS: Shielding estimates ranged from $173,000 to $418,000. The percentage of respondents accepting high-density modular or lead shielding (for union and non-union settings) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Shielding acceptance was associated with greater number of radiation oncologists in a respondent's department but not time in practice or the American Brachytherapy Society membership. Peru's experience noted cost savings with Co-60 of $52,400 annually. CONCLUSIONS: By comparing the cost of additional shielding for a sample institution's HDR suite with radiation oncologists' WTP, this multi-institutional collaboration noted < 20% of clinicians would accept additional shielding. Despite low acceptability in the US, Co-60 demonstrates cost-favorability in Peru and may similarly in other locations.

A national survey of HDR source knowledge among practicing radiation oncologists and residents: Establishing a willingness-to-pay threshold for cobalt-60 usage.

PURPOSE: Ir-192 is the predominant source for high-dose-rate (HDR) brachytherapy in United States markets. Co-60, with longer half-life and fewer source exchanges, has piloted abroad with comparable clinical dosimetry but increased shielding requirements. We sought to identify practitioner knowledge of Co-60 and establish acceptable willingness-to-pay (WTP) thresholds for additional shielding requirements for use in future cost-benefit analysis. METHODS AND MATERIALS: A nationwide survey of U.S. radiation oncologists was conducted from June to July 2015, assessing knowledge of HDR sources, brachytherapy unit shielding, and factors that may influence source-selection decision-making. Self-identified decision makers in radiotherapy equipment purchase and acquisition were asked their WTP on shielding should a more cost-effective source become available. RESULTS: Four hundred forty surveys were completed and included. Forty-four percent were ABS members. Twenty percent of respondents identified Co-60 as an HDR source. Respondents who identified Co-60 were significantly more likely to be ABS members, have attended a national brachytherapy conference, and be involved in brachytherapy selection. Sixty-six percent of self-identified decision makers stated that their facility would switch to a more cost-effective source than Ir-192, if available. Cost and experience were the most common reasons provided for not switching. The most common WTP value selected by respondents was <$25,000. CONCLUSIONS: A majority of respondents were unaware of Co-60 as a commercially available HDR source. This investigation was novel in directly assessing decision makers to establish WTP for shielding costs that source change to Co-60 may require. These results will be used to establish WTP threshold for future cost-benefit analysis.

Synchronous gynecologic malignancy and preliminary results of Lynch syndrome.

OBJECTIVE: Lynch syndrome is a hereditary cancer syndrome that increases the risks of colorectal and gynecologic malignancies such as endometrial and ovarian cancer. Studies have shown that mutations in mismatch repair genes (MSH2, MSH6, and MLH1) are associated with Lynch syndrome. The aim of our study was to estimate the value of MSH2, MSH6, and MLH1 immunohistochemistry based on family history in a Korean sample. METHODS: Thirty six women with synchronous gynecologic tumors of endometrial and ovarian cancer were identified among patients being treated at our institution. Among them, 32 patients had tumor blocks (total 62 slides) available for analysis. According to a diagnostic algorithm, we performed immunohistochemistry analyses. Staining was scored based on intensity and proportion (negative or 0: intensity undetectable or minimal, proportion <5%; weak or 1+: intensity mild, proportion 5-30%; strong or 2+: intensity moderate to marked, proportion 30-99%). RESULTS: Among 32 eligible patients, 9 (28%) had a family history of cancer. Six patients (19%) were negative for MLH1; among them, four (4/6) were negative at both sites. Nine patients (28%) were negative for MSH2 or MSH6 at both sites or negative for both MSH2 and MSH6. Among these three patients showed negative staining for both sites. The three patients showing negative staining for MLH1, MSH2, and MSH6 at both sites with family history were considered to be the screening positive groups of Lynch syndrome. CONCLUSION: In this study, the frequency of Lynch syndrome associated immunohistochemical staining (MLH1, MSH2, and MSH6) group was estimated as 9% (3/32) among Korean women with synchronous gynecologic tumors.

Tumor del estroma gastrointestinal / Tumor of the gastrointestinal stroma

Los tumores del estroma gastrointestinal, conocidos según sus siglas en inglés como GIST (gastrointestinal stromal tumors), son tumores mesenquimales que aparecen en cualquier lugar a lo largo del tracto intestinal. Este trabajo tiene el propósito de presentar una paciente de 60 años de edad que asiste a la consulta de ginecología del Instituto Nacional de Oncología y Radiobiología, por presentar dolor en el epigastrio, que se irradia al flanco derecho, con un aumento de volumen en la fosa iliaca derecha, y por ultrasonografía se plantea un tumor de ovario derecho, que se proyecta hacia el epigastrio y a hipocondrio derecho. Se describe la intervención quirúrgica y los hallazgos encontrados en estudios macro y microscópicos, así como en estudios posteriores por inmunohistoquímica de la lesión. Se concluye con un diagnóstico de tumor del estroma gastrointestinal y los resultados de las intervenciones quirúrgicas y medicamentosas realizadas. Se recomienda valorar la importancia de una estrecha relación entre cirujanos generales y ginecólogos frente a enfermedades inesperadas, por su difícil diagnóstico preoperatorio, que conllevan a un tratamiento quirúrgico adecuado, y que por la complejidad que requieren, necesitan de la competencia de ambas especialidades quirúrgicas(AU)

The tumors of the gastrointestinal stroma, known in English language as GIST (gastrointestinal stromal tumors) are mesenchymal tumors appearing in any place throughout the intestinal tract. The objective of present paper is to present the case of a female patient aged 60 came to Genecology consultation of the National Institute of Oncology and Radiobiology due pain in epigastrium irradiating to right flank with increase of volume in the right iliac fossa and by ultrasonography it is a tumor of right ovarium projecting to epigastrium and the right hypochondrium. The surgical intervention is described as well as the findings noted in macro- and microscopic studies, as well ass in latter studies by immunohistochemistry of lesion. We conclude with a diagnosis of tumor of gastrointestinal stroma and the results of performed surgical and drugs interventions. It is recommended to assess the significance of a close relationship among general surgeons and gynecologists in face of unexpected diseases due to its difficult preoperative diagnosis leading to a appropriate surgical treatment due to its complexity it is necessary the competence of both surgical specialties(AU)