Evaluation of IOTA-ADNEX Model and Simple Rules for Identifying Adnexal Masses by Operators with Varying Levels of Expertise: A Single-Center Diagnostic Accuracy Study.

Objectives The discrimination of ovarian lesions presents a significant problem in everyday clinical practice with ultrasonography appearing to be the most effective diagnostic technique. The aim of our study was to externally evaluate the performance of different diagnostic models when applied by examiners with various levels of experience. Methods This was a diagnostic accuracy study including women who were admitted for adnexal masses, between July 2018 and April 2021, to a Greek tertiary oncology center. Preoperatively sonographic data were evaluated by an expert gynecologist, a 6 th and a 1 st year gynecology resident, who applied the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model to discriminate between benign and malignant ovarian tumors. The explant pathology report was used as the reference diagnosis. Kappa statistics were used for the investigation of the level of agreement between the examined systems and the raters. Results We included 66 women, 39 with benign and 27 with malignant ovarian tumors. ADNEX (with and without "CA-125") had high sensitivity (96-100%) when applied by all raters but a rather low specificity (36%) when applied by the 1st year resident. SR could not be applied in 6% to 17% of the cases. It had slightly lower sensitivity, higher specificity, and higher overall accuracy, especially when applied by the 1st year resident (61% vs. 92%), compared to ADNEX. Conclusion Both ADNEX and SR can be utilized for screening in non-oncology centers since they offer high sensitivity even when used by less experienced examiners. In the hands of inexperienced examiners, SR appears to be the best model for assessing ovarian lesions.

The impact of HCG in IVF Treatment: Does it depend on age or on protocol?

OBJECTIVE: to evaluate the effect of the addition of low dose human chorionic gonadotropin (hCG) to human menopausal gonadotropin (HMG) throughout the early follicular phase in controlled ovarian stimulation (COS) conducted with two difference regimens. Gonadotropin-releasing hormone (GnRH) antagonist and short GnRH-agonist protocol were applied in two in vitro fertilization (IVF) clinics. METHODS: Clinical study conducted during the period 2014-2016 in two IVF clinics in a cohort of 240 women. In the first group 1 (124 women), a GnRH antagonist protocol with HMG and addition of low dose (100IU/day) h CG was applied. The other group 2 consisted of 116 women who underwent a short GnRH- agonist protocol with HMG and addition of low dose (100IU/day) h CG. RESULTS: Multiple logistic regression analysis was performed. The group 2 found to be associated with greater number of follicles and oocytes. The pregnancy rates were 12.1% and 26.7% in group 1 and group 2, respectively (p=0.004). For patients over 40 years, the number of follicles and oocytes retrieved were significant higher in group 2.The pregnancy rate in group 2 was higher than in group 1 (21, 6% vs 5%, p=0.017). CONCLUSIONS: Advanced age women are likely to achievepregnancy using the GnRH Short than GnRH antagonist, when HMG/hCG is used, while HMG-hCG gonadotropins have the same potentialas Recombinant follicle stimulating hormone (rFSH)-hCG used in GnRH short protocol.

A salpingeal carcinoma revealed after prophylactic salpingoophorectomy in an asymptomatic BRCA1 carrier with breast malignancy.

INTRODUCTION: BRCA1 inherited mutation carriers face a lifetime risk of 72% to develop breast cancer and a percentage of 44% risk for ovarian cancer. PRESENTATION OF CASE: We present a case of a 35-year old Caucasian woman who, after the excision of a possible malignant finding on the right breast, was diagnosed with ductal breast carcinoma. The patient treatment included first chemotherapy and radiotherapy and then prophylactic bilateral mastectomy with plastic reconstructive surgery. At the age of 37, she underwent prophylactic laparoscopic bilateral salpingoophorectomy. The histological diagnosis of the surgical specimens was suggestive of a unilateral invasive high grade salpingeal cancer and the patient underwent an abdominal hysterectomy by laparotomy, omentectomy and bilateral pelvic lymphadenectomy. DISCUSSION: Women with known BRCA mutations are strongly recommended to consider a risk reducing prophylactic salpingoophorectomy (RRSO) from their early 40 s to gain maximum benefit in cancer risk reduction from the procedure. The prevalence of occult carcinomas in BRCA1 carriers is almost 1, 5% if the prophylactic bilateral salpingoophorectomy is performed before the age of 40, while this percentage may be increased to 3, 8% for women who undergo the surgery between 40 and 49 years. CONCLUSION: We present an interesting case, of an accidentally revealed salpingeal carcinoma via RRSO in an asymptomatic young premenopausal woman.

Recurrent benign leiomyomas after total abdominal hysterectomy. Rich or poor estrogenic environment may lead to their recurrence?

INTRODUCTION: Benign metastasizing leiomyomas represent benign lesions consisted by leiomatosous tissue and could be observed in positions away from their usual localization, the human uterus. They commonly affect women that have undergone total hysterectomy. Approximately 100 similar cases have been reported in the literature, so the case we present is rare and reviewing the literature and needs to be reported. PRESENTATION OF CASE: We report a case of a 55 year old Greek woman, gravida five and para three, who attended our unit 3 years ago complaining of occasionally lower abdominal pain and irritation the last months. Fourteen years ago she underwent abdominal hysterectomy and left salpingo-oophorectomy due to a 13 cm uterine leiomyoma. In the meantime she underwent two surgical procedures for recurrent benign leiomyomas. DISCUSSION: When patient was admitted at this time, clinical examination revealed a palpable mass of 5 cm. The transvaginal ultrasonography revealed 3 masses in the lower pelvis of unknown origin. The patient underwent a new laparotomy revealing three masses of benign leiomyomas with low mitotic activity. CONCLUSION: Our case supports the recurrent appearance of leiomyomas in pelvis after total abdominal hysterectomy and is one of few reports in literature where the tumors appear in the same patient both in estrogen rich and estrogen poor environment. Additionally, we show the importance of transvaginal ultrasonography and 3 dimensional power Doppler in the differential diagnosis of pelvic masses. Thus, transvaginal ultrasonography seems to be a pivotal tool for the diagnosis and follow up of these challenging lesions.

A unique case of total metastatic lobular breast carcinoma, originating from diffused microcalcifications, presented in a postmenopausal woman, without clinical manifestations.

INTRODUCTION: Lobular breast carcinoma includes lobular carcinoma in situ (LCIS) and invasive lobular carcinoma (ILC). The association of LCIS with total metastatic lobular breast cancer is very rare. PRESENTATION OF CASE: We present a case of a totally metastatic lobular breast cancer in an asymptomatic 64-year-old postmenopausal woman, with no suspicious microcalcifications in mammography. A total hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, infracolic omentectomy and appendectomy was performed along with a quadrantectomy of the upper outer quadrant of left breast, and systematic isolateral lymphadenectomy of the left axilla. DISCUSSION: LCIS is usually undetectable because it isn't associated with clinical abnormalities in clinical examination and is presented in mammography as microcalcifications or focal asymmetric densities. ILC histopathologic features are responsible for the high false-negative rates on mammography, leading to moderate detection sensitivity. CONCLUSION: Our case is a very rare condition. No 'similar' case have been described in the literature so far.

Ovarian vein thrombosis after total laparoscopic hysterectomy with unilateral adnexectomy: A case report.

INTRODUCTION: Ovarian vein thrombosis is a rare but potentially serious complication after surgical and gynecologic procedures such as oophorectomy and hysterectomy. The association of this event with laparoscopic hysterectomy in particular, is very rare. Only two cases have been described so far. PRESENTATION OF CASE: We present a case of ovarian vein thrombosis after laparoscopic hysterectomy in a 40-year-old with deep endometriosis and multiple intramural uterine myomas. Laparoscopic hysterectomy, left oophorectomy, right salpingectomy, and suspension (ovariopexy) of the right ovary on the ipsilateral round ligament of the uterus were performed, using bipolar electrocautery as a hemostatic tool. DISCUSSION: The 7th postoperative day the patient presented to our hospital complaining of abdominal pain and fever. An abdominal CT scan demonstrated a filling defect and enlargement of the right ovarian vein, a finding compatible with ovarian vein thrombosis. She was treated with low molecular weight heparin (LMWH). On the 19th postoperative day, an MRI scan was performed and did not reveal any pathological findings of the right ovarian vein. The patient was discharged on LMWH for three months. Post treatment evaluation for thrombophilia was negative for pathological findings. CONCLUSION: Our case is a very rare condition. Only two 'similar' cases have been described in the literature so far. Bipolar electrocautery and ovariopexy on the ipsilateral round ligament during laparoscopic hysterectomy should be evaluated further as possible contributing mechanisms for the thrombus formation.

Mesenteric cysts and mesenteric venous thrombosis leading to intestinal necrosis in pregnancy managed with laparotomy: a case report and review of the literature.

BACKGROUND: Mesenteric cyst is a rare clinical entity especially in pregnancy; therefore, few cases have been reported in the literature. The standard method of their treatment is surgical excision either with laparotomy or laparoscopy. In addition, mesenteric vein thrombosis is a rare and life-threatening condition in pregnancy and needs immediate treatment because it can lead to intestinal necrotic ischemia. This is the first report of the coexistence of mesenteric cysts and mesenteric vein thrombosis during gestation. CASE PRESENTATION: A 27-year-old Greek woman, gravida 2 para 1, presented at 10 weeks' gestation to the Emergency Unit of our hospital complaining of diffuse abdominal pain which deteriorated the last 3 days, which was localized in her right iliac fossa, along with vomiting. She had undergone open laparotomy and right salpingo-oophorectomy at the age of 23 due to an ovarian cyst. Besides this, her personal and family medical history was unremarkable. She had never received oral contraceptives or any hormone therapy. On arrival, a clinical examination revealed tenderness on palpation of her right iliac fossa, without rebound tenderness or muscle guarding. Within 10 hours of hospitalization, her symptoms deteriorated further with rebound tenderness during the examination, tachycardia, and a drop of 12 units in her hematocrit value. An emergency laparotomy was performed. Two mesenteric cysts and a 60 cm necrotic part of her intestine were revealed intraoperatively. In the postoperative period, she complained of acute abdominal pain, tachycardia, and dyspnea. Computed tomography imaging revealed mesenteric vein thrombosis and pulmonary thromboembolism. She was treated with low molecular weight heparin and she was discharged on the 11th postoperative day. CONCLUSIONS: To the best of our knowledge, this is the first report in the literature of a simultaneous mesenteric cyst and mesenteric vein thrombosis in pregnancy. It is known that pregnancy is a state of hypercoagulation and clinicians should bear in mind this rare clinical condition in their diagnostic algorithm for acute abdominal pain.

A prepubertal giant juvenile fibroadenoma in a 12-year-old girl: Case report and brief literature review.

INTRODUCTION: Giant juvenile fibroadenomas represent only the 0.5% of all fibroadenomas, constituting a rare condition in adolescence. In prepuberty, the presence of this condition is extremely rare. PRESENTATION OF CASE: We describe a rare case of a 12- year-old Caucasian girl who presented to our Hospital complaining of a palpable mass with rapid enlargement in her right breast that she had first noticed 3 months ago. Her menarche hadn't occurred yet. DISCUSSION: Physical examination showed a giant mass of 15 × 13 cm in the right breast. The patient was further evaluated via ultrasonography showing a sole large lesion of 13 × 12 cm in the right breast. A surgical procedure under general anesthesia was performed. Histopathological findings after the surgical excision were suggestive of giant juvenile fibroadenoma. The patient has a normal breast development over a period of 9 month follow up. CONCLUSION: Giant juvenile fibroadenomas should be included in differential diagnosis of a breast mass in prepubertal girls despite the fact that they are very rare in prepuberty, tend to appear later during adolescence and their prevalence is lower in Caucasians. The remarkable size and the rapid growth of the lesion should not be ruled out in the diagnostic process of an adolescent breast.