Expression of E-cadherin in primary endometrial carcinomas: clinicopathological and immunohistochemical analysis of 30 cases.

INTRODUCTION: Decreased expression of E-cadherin has been associated with poorly differentiated endometrial carcinomas and poorer outcomes. AIM: The purpose of this study was to examine the distribution of E-cadherin immunohistochemical expression in specimens from primary endometrial carcinomas and its relation to classical clinicopathological prognostic factors. MATERIALS AND METHODS: Surgically-resected tissues of 30 patients with primary endometrial carcinomas were studied. Histological type and grade, depth of myometrial invasion, lymph-vascular space invasion, fallopian tube or ovarian invasion, and the presence of tumoral necrosis were evaluated. Immunohistochemical examination was performed on deparaffinized four-microm-thick sections. RESULTS: The mean age of patients was 65 years (+/- 11.41). The 63.54% of carcinomas were moderately/poorly differentiated. No statistical correlation was found between the score or intensity of E-cadherin immunohistochemical staining (strong or moderate positive expression) and the clinicopathological factors tested. CONCLUSIONS: The association of E-cadherin immunoreactivity with the standard clinicopathological factors seemed to be contradictory. The classical clinicopathological factors remain the most important prognostic parameters.

Peritonitis due to iatrogenic colpotomy after large loop excision of the transformation zone (LLETZ) in a patient with cervical intraepithelial neoplasia III: our experience of a rare case with review of the literature.

A case of peritonitis as an unusual complication of LLETZ (large loop excision of the transformation zone) for the treatment of CIN III associated with unrecognized iatrogenic posterior colpotomy is presented. After the procedure, the patient developed fever 38.3 degrees C and diffused severe pelvic pain. The contributing factors, prevention and management of this complication are discussed. Also, the complications of cold knife cervical conization and LLETZ procedure are reviewed.

Antenatal sonographic diagnosis of pharyngeal teratoma: our experience of a rare case with review of the literature.

Background. Teratomas are the most common tumors. They are usually localized in the sacrococcygeal area, while the pharyngeal localization is very rare. The number of cases of stomatopharyngeal teratomas detected prenatally via sonography is very small. Case Report. We present the case of a 24-year-old primipara at 18 weeks' gestation, that at the routine ultrasound scan, the fetus was found with an echogenic mass, filling the stomatopharyngeal cavity and protruding from the mouth. Other abnormalities were not found. Termination of pregnancy was achieved using misoprostol. A female stillborn fetus with a weight of 250 g and length of 25.5 cm was delivered. The postmortem and pathologic examination confirmed the diagnosis. Conclusion. Pharyngeal teratomas can be diagnosed with the use of ultrasounds in utero facilitating parents' counseling in early time.

Tubal ectopic pregnancy associated with an extraskeletal chondroma of the fallopian tube: case report.

Extraskeletal chondroma is a relatively uncommon benign soft tissue tumor, which usually occurs in the hands and feet. The tumor may also occur around the tendon, synovium, or joint capsule. Rare sites are the tongue, testes and liver. Chondroma of the fallopian tube is extremely rare, with only two reports in the English literature. We present the first reported case of extraskeletal chondroma of the fallopian tube causing transportation impairment of the fertilized ovum in a 32-year-old gravida 1, para 1 woman.

Angiomyofibroblastoma of the vagina in a postmenopausal breast cancer patient treated with tamoxifen: clinicopathologic analysis of a case and review of the literature.

Angiomyofibroblastoma is a rare mesenchymal tumor. This study presents the clinical, histologic, and immunohistochemical features of an angiomyofibroblastoma of the vagina occurring in an 80-year-old breast cancer patient under prolonged treatment with tamoxifen. Histologically, the tumor was characterized by alternating hypercellular and hypocellular edematous zones and small- to medium-sized blood vessels, which were characteristically thin walled. The tumor cells were spindle shaped (mainly) or round shaped (occasionally) arranged in cords and nests. The stroma was edematous and contained inflammatory cells, especially lymphocytes and mast cells. Immunohistochemistry of the tumor cells revealed diffuse and intense immunoreactivity for vimentin and desmin. The staining for estrogen receptors and progesterone receptors was positive, with a percentage of 70% and 40%, respectively. In conclusion, the tumor was diagnosed as an angiomyofibroblastoma based on its typical histologic and immunohistochemical features. The expression of estrogen and progesterone receptors suggests that it might arise as a neoplastic proliferation of hormonally responsible mesenchymal cells. Tamoxifen may exert stimuli effects upon mesenchymal cells.

Aggressive angiomyxoma of the vulva: our experience of a rare case with review of the literature.

Aggressive angiomyxoma is a rare, benign but locally aggressive mesenchymal neoplasm, which occurs almost exclusively during the reproductive years of women. A 28-year-old woman developed an aggressive angiomyxoma within the left labium minus of the vulva. The tumor was excised, but the lesion was expanded to the surgical margins. Microscopically, sections showed many walled vessels of various sizes, a loose myxoid and collagenous stroma and stellate and spindle-shaped neoplasmatic cells. Immunohistochemically, the neoplasmatic cells showed strong positivity for vimentin and desmin and moderate positivity for CD34 and estrogen receptors. In conclusion, aggressive angiomyxoma of the vulva should be distinguished from the benign and malignant myxoid tumors or tumor-like conditions of vulva. The pathologic and immunohistochemic characteristics, the difficulties in determining the surgical margins and the treatment of this tumor are discussed. Also, the international literature is reviewed.

Isolated torsion of the fallopian tube: a case report and review of the literature.

INTRODUCTION: Isolated torsion of the fallopian tube is a very rare condition. It occurs without ipsilateral ovarian involvement associated with pregnancy, haemosalpinx, hydrosalpinx, ovarian or paraovarian cysts and other adnexal alterations or even with an otherwise normal fallopian tube. We document a case of isolated torsion of the right fallopian tube associated with hydrosalpinx. CASE: The patient was a 39-year-old female, para 2, gravida 4, who was presented with acute pelvic pain, nausea and vomiting. Her medical history included an appendectomy and right hydrosalpinx diagnosed five months before admission by hysterosalpingography because of investigation for secondary infertility. The urinary pregnancy test was negative. Pelvic ultrasonography showed a dilated folded right tubular structure measuring 7.8 x 2.7 cm with thickened echogenic walls and mucosal folds protruding into the lumen; the ovaries and uterus were unremarkable. No free fluid in the cul-de-sac was noted. Preoperatively, a diagnosis of twisted right fallopian tube was suspected and an exploratory laparotomy confirmed the diagnosis of isolated torsion of the oviduct. The ipsilateral ovary appeared normal, but the fallopian tube was gangrenous and right salpingectomy was performed. The patient became pregnant three months after surgery. CONCLUSION: Isolated torsion of the fallopian tube should be considered in the differential diagnosis of patients with acute abdomen and previous medical history of hydrosalpinx.

Primary fallopian tube adenocarcinoma: preoperative diagnosis, treatment and follow-up.

Preoperative diagnosis of fallopian tube carcinoma is difficult due to the rarity and silent course of this neoplasm. We present herein the case of a 58-year-old woman with primary fallopian tube carcinoma that was diagnosed preoperatively on the basis of a positive for adenocarcinoma Papanicolaou vaginal smear, repeated episodes of vaginal bleeding, negative endocervical and endometrial curettage, characteristic features on ultrasonography and elevated CA-125 levels. The patient was treated by total abdominal hysterectomy, bilateral salpigno-oophorectomy and omentectomy. Pathologic confirmation of primary serous papillary adenocarcinoma of the left fallopian tube was made. Peritoneal washings were positive for malignancy. FIGO stage was considered as IIIb and the patient received six courses of combined carboplatin-taxol chemotherapy. At two years from onset of therapy the patient underwent a modified radical mastectomy and lymphadenectomy because of primary carcinoma of the right breast. The patient was started on tamoxifen therapy, which she is still taking. At 60 months after initial surgery, the patient is alive and well. In conclusion, our study suggests an association between fallopian tube carcinoma and breast cancer and a good response of the patient to platinum-based chemotherapy.

Primary ovarian carcinosarcoma: a case report and review of the literature.

Primary ovarian carcinosarcoma is characterized by an admixture of malignant epithelial and stromal elements. This neoplasm is extremely rare with fewer than 400 cases reported in the English literature. Its histogenesis, clinical features and optimal treatment remain unclear because of the rarity of primary ovarian carcinosarcoma. This study focuses on the clinical, pathological, immunohistochemical features and survival of a 73-year-old patient with primary ovarian carcinocarcoma. The patient was treated with surgery followed by combined chemotherapy with carboplatin and taxol and assigned to FIGO Stage IIIc. She died from the disease 17 months after surgery. In conclusion, ovarian carcinosarcoma is a very aggressive tumor, especially when it is diagnosed at advanced stage.

Benefits and limitations of ultrasonographic evaluation of uterine adnexal lesions in early detection of ovarian cancer.

Ovarian cancer is the most frequent cause of death from gynaecological malignancies in the Western world. Most cases of epithelial ovarian cancer are detected at late stages and the resultant overall five-year survival is poor. However, when epithelial ovarian cancer is detected with the disease confined to the ovary the prognosis is favorable. Transvaginal gray-scale ultrasonography and colour Doppler assessment of blood flow have been evaluated as methods to predict risk of malignancy in ovarian tumours. In order to reduce the number of unnecessary surgical procedures for uterine adnexal tumours, ultrasonomorphologic scoring systems have been developed, assigning numerical ultrasonographic parameters of the tumours. However, the positive predictive value of these scoring systems is low and this is due to the fact that the appearance of many benign ovarian lesions overlaps with that of malignant disease. In addition, some ovarian malignancies are ultrasonographically detected as simple cysts without exhibiting a complex morphology. Moreover, the cut-off size of uterine adnexal tumours for surgical intervention in the early detection of cancer is not yet well determined. The application of colour blood-flow imaging is very helpful in the detection of uterine adnexal malignancy because of the presence of neovascularization in malignant tumours. When gray-scale ultrasonography detects the presence of septum or papillary projections or solid components in uterine adnexal lesions and Doppler flow is present within these lesions malignancy is likely. However, the detection of vascularity within the papillary projection of a malignant tumour may not be detected when it is very small. When colour-flow imaging is used in premenopausal patients attention is needed to avoid confusion of luteal flow with flow of cystic lesions. Initial reports using pulsed Doppler ultrasonography showed high sensitivity and specificity in the detection of ovarian cancer when levels of the resistive index (RI) less than 0.4 and levels of the pulsatility index (PI) less than 1 were used. Subsequent studies have shown considerable overlap of RI and PI rates between benign and malignant uterine adnexal masses, suggesting that pulsed Doppler ultrasonography is not an independent indicator for malignancy. Serum CA-125 levels have been used in conjunction with ultrasonography to identify as many of the false-positive results in order to avoid unnecessary surgery. In postmenopausal women with a uterine adnexal mass the combination of physical examination with serum CA-125 levels and pelvic ultrasound scan seems to improve the sensitivity and specificity of predicting adnexal malignancies. In contrast, in premenopausal women the consideration of CA-125 levels with Doppler ultrasonographic findings might confuse the differential diagnosis of ovarian masses. In conclusion, accurate selection of patients with uterine adnexal tumours for surgical intervention is not provided by pelvic ultrasonography. Pelvic ultrasonography as a screening method for the early detetection of ovarian cancer should be probably limited to those women who are at increased risk for development of ovarian cancer and not in the general population.

Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature.

This pilot case-control study was carried out to determine the value of intraperitoneal irrigation with a long-acting local anaesthetic agent in reducing postoperative analgesic requirements following gynaecological operative laparoscopy. Twenty women undergoing gynaecological laparoscopic surgery were recruited to receive dilute bupivacaine instilled into the peritoneal cavity at the completion of surgery. Analgesic requirements were assessed during the first 10 hours, and pain scores at 4 and 24 hours. Analgesic requirements were then compared with historical controls. Our results revealed that the total parenteral opioid requirement after bupivacaine was significantly less than in the control group (0.50 mg vs. 7.17 mg, P=0.006). Oral analgesic requirements were not significantly different between the two groups. Pain scores in the bupivacaine group showed no difference at 4 and 24 hours postoperatively. Intraperitoneal irrigation with dilute bupivacaine at the end of gynaecological laparoscopic surgery appears to reduce early postoperative analgesic requirements in this pilot study.

Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings.

INTRODUCTION: Uterine adnexal torsion is a rare and potentially lethal condition that may arise most unexpectedly in women of any age. It may be partial or complete, the later often resulting in necrosis, gangrene and peritonitis if untreated. The purpose of the study was to determine the spectrum of the histologic and gray-scale sonographic pictures in a series of surgically proven cases of uterine adnexal torsion. METHODS: The study population for the pathologic analysis of twisted uterine adnexa included 92 patients with surgical confirmation of torsion of the uterine adnexa; all the patients were treated radically. All the pathology records were reviewed retrospectively over a 10-year period (from 1992 to 2002) by the coding of ovarian, fallopian tube or adnexal torsion. The gray-scale sonographic findings were analysed in 20 patients who underwent sonographic examination before surgery and adnexal torsion was confirmed at surgery. RESULTS: Neoplasms constituted 46% (42/92) and cysts formed 48% (44/92) of all the twisted uterine adnexa. Normal-sized twisted adnexa were found in five patients (5%) while in one patient simultaneous torsion of both normal fallopian tubes was found (1%). The prevalence of the twisted neoplasms was 16 mature teratomas, nine serous cystadenomas, five mucinous cystadenomas, three serous borderline carcinomas, two fibroma/thecomas, two mucinous borderline carcinomas, two malignant granulosal-stromal cell tumours, one malignant dysgerminoma, one immature teratoma and one clear cell adenocarcinoma. The twisted cysts were 18 serous cysts, 11 paraovarian cysts, nine corpus luteum cysts, three hydrosalpinges, one mucinous cyst and one endometrioma. In one case the torsion of the right ovary was due to hyperstimulation of the ovaries with gonadotropin therapy for IVF treatment. Gray-scale sonographic examination demonstrated cystic lesions in 80% (16/20), solid masses in 5% (1/20) and normal adnexa in 15%; cul-de-sac fluid was present in 55% (11/20). Laparotomy revealed reactive cul-de-sac fluid in ten of these cases (50%) and haemoperitoneum in one (5%). CONCLUSION: Adnexal torsion is most commonly associated with benign processes (89%) and usually occurs in patients under 50 years old (80%). The spectrum of sonographic findings varies due to the adnexal pathology, the degree and the duration of adnexal torsion.

Internal hemorrhage caused by a twisted malignant ovarian dysgerminoma: ultrasonographic findings of a rare case and review of the literature.

PURPOSE: Ovarian cancer presents as an acute abdomen very rarely. The purpose of the study is the description of a right ovarian malignant dysgerminoma presenting as an abdominal emergency. CASE: A 16-year-old white female presented with acute abdominal pain in the right iliac fossa. On physical examination the abdomen was acute and a mass in the right lower abdomen was palpated. The patient was sexually active and bimanual gynecological examination revealed the presence of a large lobulated solid tumor in the position of the right adnexa. Ultrasound examination showed the presence of a large, multilobulated, heterogeneous, predominantly solid pelvic mass. Color flow imaging showed intratumoral flow signals. The uterus and the left ovary had normal size and echo-texture. Fluid was found in the cul-de-sac and in Morisson's space. An immediate exploratory laparotomy exposed the presence of a twisted right ovarian mass and intraperitoneal hemorrhage. A superficial tumoral vessel actively bleeding was seen. Peritoneal fluid was obtained for cytology. The intra-abdominal hemorrhage ceased when the ovarian pedicle was clamped. The patient underwent right salpingo-oophorectomy and biopsy of the omentum. Pathologic analysis revealed a malignant dysgerminoma of the right ovary, expanding to the mesosalpinx. Cytology was positive for malignancy. Postoperative CT scan of the upper and lower abdomen was negative. The patient was assigned to FIGO Stage IIC and referred for platinum-based chemotherapy. CONCLUSION: Ovarian malignant dysgerminoma may present as an acute abdomen because of torsion, passive blood congestion, rupture of superficial tumoral vessels and subsequent intra-abdominal hemorrhage. Ovarian dysgerminoma should be part of the differential diagnosis in a young woman with acute surgical abdomen and a solid heterogeneous pelvic mass detected by ultrasonographic scan.

The problems with different management options of women with minor squamous intraepithelial lesions in Pap tests.

The optimum management of women with minor squamous intraepithelial lesions in Pap tests is controversial. With cytological surveillance after one Pap test showing atypical cells of undetermined significance (ASCUS), a significant proportion of women will have undiagnosed squamous intraepithelial lesions. On the other hand, using immediate colposcopy for ASCUS almost half of the women would not have needed the procedure. This number for referral for colposcopy can be reduced to only those women who test positive for high-risk HPV-DNA, however some women will have undiagnosed squamous intraepithelial lesions. In addition, when surveillance with repeat Pap tests is used for the management of low-grade cervical squamous intraepithelial lesions (LSIL) a significant number of high-grade cervical intraepithelial lesions can be missed. In this article all the problems of each management policy in women with minor squamous intraepithelial lesions in Pap tests are addressed.

Multiple dermoid cysts within the same ovary: our experience of a rare case with review of the literature.

OBJECTIVE: Ovarian dermoid cysts are relatively frequent ovarian lesions that can be easily diagnosed by transvaginal ultrasonography. However, the recognition of multiple dermoid cysts, separated by normal ovarian tissue, within a single ovary is rare. CASE: We present a case with bilateral dermoid cysts, four dermoid cysts within the right ovary and one in the contralateral ovary. Transvaginal ultrasonography showed hyperechogenic areas in the right ovary with a hypoechogenic area in front of them; the hyperechogenic areas were separated by areas with the echogenicity of normal ovarian tissue and indentation, suggesting the presence of multiple dermoid cysts within the same ovary. CONCLUSION: Preoperative ultrasonographic suspicion of multiple dermoid cysts within the same ovary might contribute to a better decision about the surgical approach.

Action of 25 microg 17beta-oestradiol vaginal tablets in the treatment of vaginal atrophy in Greek postmenopausal women; clinical study.

PURPOSE: To evaluate the clinical efficacy and safety of intravaginal application of 25 microg micronized oestradiol in postmenopausal women from the Greek population suffering from symptoms related to vaginal atrophy. MATERIALS AND METHODS: 91 women suffering from vaginal dryness, vaginal itching and dyspareunea were treated with 25 microg 17beta-oestradiol vaginal tablets. The duration of treatment was 12 weeks. During the first two weeks the women inserted one vaginal tablet intravaginally once daily. Thereafter, the women inserted one tablet twice per week with at least a 3-day interval between treatments to maintain therapeutic response for ten weeks. Efficacy was evaluated by the relief of vaginal symptoms and safety by the concentrations of serum oestradiol (E2) and follicular-stimulating hormone (FSH). Pretreatment and post-treatment findings were compared and each patient served as her own control. RESULTS: The rates of symptoms of vaginal dryness, vaginal itching and dyspareunea showed statistically significant differences over the course of the trial (Cochran Q test, p < 0.001). No one complained of vaginal dryness and vaginal itching after four and six weeks of treatment respectively, while in one patient the sensation of dyspareunea remained constant after the fourth week of treatment. Despite the statistically significant increase in blood oestradiol levels in relation to baseline values (ANOVA model of repeated measures, p < 0.001), these levels were within the normal range for postmenopausal women. Also, serum FSH levels were statistically significantly reduced from 47.4 mIU/ml at entry into the study to 45.5 mIU/ml after two weeks of treatment (dependent samples t-test, p < 0.003), but were clearly within the postmenopausal range. CONCLUSIONS: The twice-weekly local single treatment with vaginal tablets containing 25 microg of 17beta-oestradiol was effective and safe for the relief of symptoms related to atrophic vaginitis in postmenopausal women from the Greek population.

Mucinous cystadenoma of the ovary with functioning stroma and virilization in pregnancy: a case report and review of the literature.

Virilization caused by ovarian tumors with functioning stroma during pregnancy is extremely rare and has been reported in many ovarian tumors. In mucinous cystadenomas with maternal virilization during pregnancy the stromal cells responsible for the hormone secretion resemble lutein or Leydig cells and have been referred to as luteinized stromal cells. We present a case of a 30-year-old, gravida 2, para 1, woman who presented at approximately the 38th week of pregnancy with features of virilization. At the same time, a cesarean section was performed because of fetal distress and a male weighing 3,030 g without any gross abnormalities was delivered. A large tumor of the right ovary was detected and a right salpingo-oophorectomy was performed. Histopathologically, the tumor proved to be a benign mucinous cystadenoma. Masses typically resembling lutein stromal cells or Leydig cells of the testes or ovarian hilus were found in the wall of the cyst below the mucinous epithelium. No crystalloids of Reinke were identified. The stromal component of the tumor was characterized as functioning stroma with luteinized stromal cells. The glandular mucinous epithelium showed focal positivity for human chorionic gonadotrophin. The cytoplasm of the luteinized stromal cells reacted strongly and diffusely with antiserum for vimentin. Also, the cytoplasm of the luteinized stromal cells showed focal intense positivity for synaptophysin, and focal mild positivity for human chorionic gonadotrophin. Staining results for oestrogen and progesterone receptors were negative. In conclusion, we present an unusual case of clinical virilization during pregnancy associated with an ovarian mucinous cystadenoma with functioning stroma. The virilizing manifestations disappeared after removal of the ovarian neoplasm, supporting the perception that the functioning ovarian stroma was responsible for the androgen production.

A voluminous twisted paraovarian cyst in a 74-year-old patient: case report and review of the literature.

Although paraovarian cysts rarely cause symptoms, they may be complicated due to massive size, torsion or internal haemorrhage from rupture. Moreover, benign or malignant neoplasms may occasionally develop in paraovarian cysts. The risks from voluminous ovarian or paraovarian cysts are due to severe cardiovascular, pulmonary, and circulatory problems including surgical and postoperative complications. We present a case of a 74-year-old patient who suffered from a twisted voluminous right paraovarian cyst. Her preoperative respiratory function required attention. The patient was treated surgically with good results and she showed notable improvement of her respiratory function, postoperatively. The maximum diameter of the mass was 26 cm and its total weight was 5,100 g. In addition, a simple cyst was found in the left ovary with a maximum diameter of 9.5 cm and total weight of 300 g. In conclusion, paraovarian cysts, even in elderly patients, can reach large sizes requiring awareness of the problems that these large masses may cause.

Prenatal diagnosis of congenital cystic adenomatoid lung malformation: case report and review of the literature.

Congenital cystic adenomatoid malformation of the fetal lung is an extremely rare developmental abnormality characterized by excessive overgrowth of the terminal respiratory bronchioles at the expense of the saccular spaces. We present a case of a 33-year-old, gravida 2, para 1, woman with congenital cystic adenomatoid lung malformation-type II diagnosed by ultrasound at the 20th week of gestation. On the right side of the chest an area with a maximum diameter of 18.5 mm and with small cystic lesions was recognized. The maximum diameter of the cysts was 0.5 cm. There were no other fetal abnormalities. The pregnancy was terminated and the postmortem examination confirmed the ultrasonographic findings. The cysts had the appearance of bronchiolus-like structures and were lined with cuboidal and columar epithelium. Distended alveoli were present, while the airways were normal in structure. No other congenital anomalies were found. In conclusion, in this study we describe the ultrasonographic and pathologic findings of an unusual case of congenital cystic adenomatoid malformation of the fetal lung.

Large endometrial polyp with sarcomatous stromal components following long-term tamoxifen treatment for breast cancer: a case report and review of the literature.

Tamoxifen is commonly used in the management of patients with breast cancer because of its anti-oestrogenic effects to the breasts. However, tamoxifen acts as an oestrogen agonist on the endometrium increasing the incidence of endometrial polyps, hyperplasia and cancer. In addition, it may be possible that tamoxifen increases the occurrence of uterine body tumours. We describe a rare case of a large endometrial polyp with sarcomatous stromal components in a 73-year-old breast cancer patient treated daily with 20 mg of tamoxifen for four years. The glands of the polyp were lined by benign appearing epithelium. The polyp was twisted and protruded from a dilated cervix at the entrance of the vagina. The patient was treated by removal of the polyp and dilatation and curretage. A postoperative computed tomography scan showed many focal hypodense lesions in the hepatic lobes with a well-defined profile suggestive of metastatic disease and the patient was referred for combined chemotherapy. In conclusion, a case of a mesenchymal malignant neoplasm arising in the uterus of a breast cancer patient treated with tamoxifen is reported and its clinical, histological and immunohistochemical features are discussed. Also, the international literature is reviewed.