Progestins and the Risk of Breast Cancer.

OBJECTIVES: The present paper aims to investigate the effects of both progesterone and progestin treatment mainly related to the occurrence of breast cancer in women. MATERIALS AND METHODS: Extensive systematic bibliographic review of Greek and International articles was conducted through the electronic databases Pubmed, Cinahl, Uptodate, and Google Scholar for the identification of articles related to progesterone, progestins and breast cancer treatment. RESULTS: Hormone therapy with the use of estrogen alone presents a small increased risk or does not present at all an increased risk of breast cancer. With ORs in some studies below 1.0 in current users for 3 plus years and safe option until 7 years, while in other studies the risk was increased with the ORs 1.29. However, the use of estrogen in combination with progestogens, depending on the type of progestogens, shows an increased risk of breast cancer, with the ORs to vary between 1.14- 2.38 from 3 to 5 years and is inversely proportional to the time of its use. This risk varies depending on the combination of the preparations. Other factors that are associated with breast cancer risk when receiving hormone therapy are the years that hormone therapy is taken, directly proportional to the risk. At higher risk are older women, women with low body mass index in menopause (BMI <25kg/m2) and women with increased mammographic breast density. Continued use of hormone therapy is associated with an increased risk for breast cancer compared to sequential. The risk became visible sooner to women who used in the past hormone therapy and were using it again. Starting hormone therapy in the immediate postmenopausal period also increased the risk for breast cancer. Hormone therapy was associated with tumors with positive estrogen and progesterone receptors, and also the lobular histological type was associated with its use. Tibolone use was associated with an increased risk.

ANTIMÜLLERIAN HORMONE AS INDICATOR OF OVARIAN DYSFUNCTION.

AIM: The purpose of this study was to examine various hormonal, biochemical and environmental factors (i.e., smoking and alcohol intake) and to investigate their possible correlation to the development of polycystic ovary syndrome (PCOS). The main objective was to evaluate the associations between hormonal profile and the antimüllerian hormone (AMH) levels in PCOS patients and their relation to environmental factors. PATIENTS AND METHODS: In two gynecological clinics, 38 women with PCOS (defined according to the Rotterdam criteria) were enrolled and observed in relation to AMH, follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T), Δ4-androstendione (Δ4-A), dehydroepiandrosterone sulfate (DHEA-S) and glucose plasma concentrations. Obesity, smoking and alcohol exposure were also studied. RESULTS: AMH, T, Δ4-Α, DHEA-S, LH and FSH were increased in 76.3%, 50%, 31.8%, 23.7%, 21% and 18.4% of the patients, respectively. The LH/FSH ratio and glucose concentrations increased abnormally in 18.4% and 15.8% of the patients, respectively. AMH and T levels were both increased in 47.4% of the patients whereas both AMH and LH levels increased in 21% of the patients. Smoking, alcohol intake, obesity and glucose concentrations were not associated with AMH concentrations. On the contrary, high levels of T and LH were linked to higher levels of AMH. FSH concentrations were not increased in these patients. CONCLUSION: AMH is an important hormonal parameter for the diagnosis of PCOS. Larger clinical controlled studies are necessary in an effort to further investigate the inclusion of AMH measurement in the diagnostic criteria of PCOS.

Efficiency of GnRH analogues in treating large functional ovarian cysts.

AIM: The aim of this study was to determine the potential therapeutic benefit of a single administration of a GnRH analogue in pre- menopausal women presenting large functional ovarian cysts (FOCs) (diameter > five cm). MATERIALS AND METHODS: Fifty-one patients (median age 37.4 years) diagnosed with ovarian cysts, presumed benign based on transvaginal and/or transabdominal ultrasound, were divided in three study groups. Patients of group A received no medication whereas patients of groups B and C were treated with a single administration of a GnRH analogue and combined oral contraceptives, respectively. Patients were re-examined after a three-month period. Three of the 51 patients were lost in follow-up or stopped the treatment. RESULTS: Complete resolution of the ovarian cysts was observed in eight (50%), 14 (70%), and eight (67%) patients of groups A, B, and C, respectively. No side effects were observed in either of the three groups. The positive therapeutic effect in group B did not reach statistical significance compared with the two other groups (p > 0.05). CONCLUSION: Anew option of treating large FOCS through a single-dose of a GnRH analogue is proposed and should be carefully considered. Further research is needed in order to evaluate GnRH analogues as an alternative treatment.

A large breast lump causing a diagnostic dilemma.

Lipomas are the most frequent mesenchymal tumors consisting of mature fat cells and are usually benign. They represent approximately 4-5% of all benign tumors that occur in human body. They can sometimes present very large sizes in their localization and are referred to as "giant lipomas". In this article, the authors report an unusual case of a right breast giant lipoma causing diagnostic dilemma. A 62-year-old woman was referred to the present hospital with a complaint of a sudden chest asymmetry of the right breast increasing at the connection of the pectoralis muscle. Ultrasonography revealed breast tissue involution (ACR 1). Specifically, the ultrasound findings were mostly compatible with lipid mass (lipoma) and areas with cystic necrosis. The findings from digital mammogram were not conclusive compared with ultrasound examination. Moreover, the results from the breast MRI were contradictory and other diagnosis was evinced. The patient underwent wide-surgical excision and reconstruction and had an excellent postoperative issue. According to the final histopathological examination, the tumor measured 17 cm and was covered by a thin membranous capsule. Furthermore, it had the appearance and composition of adipose tissue. In conclusion, according to the authors' view, this case is rare due to its challenging size and the difficulty in differential diagnosis.

Controversies on Transvaginal Ultrasound Screening for Endometrial Cancer in Asymptomatic Postmenopausal Women.

Endometrial cancer (EC) in postmenopausal women is usually associated with abnormal vaginal bleeding. However, asymptomatic cases of EC have been reported. The incidence of EC has been estimated to 1.3-3.05 per 1,000 screened postmenopausal asymptomatic women, the most significant ultra-sonographic feature being the thickened endometrium. We reviewed the literature on the accuracy of endometrial thickness measurement by transvaginal sonography (TVS) in predicting EC in asymptomatic postmenopausal women. The use of endometrial thickness as a sole screening test was found not to be of high predictive value and it should be combined with the evaluation of EC risk factors and followed by hysteroscopy and biopsy in suspicious cases. The lack of a universal cut-off value for endometrial thickness that could be correlated to EC is pointed out.

Features of Polycystic Ovary Syndrome in adolescence.

RATIONALE: To elucidate the prepubertal risk factors associated with the development of Polycystic Ovary Syndrome (PCOS) and determine the special clinical manifestations of the syndrome in this transitional time of a woman's life. OBJECTIVE: To propose therapeutic targets and regimens, not only to prevent the long-term complications of the syndrome, but also to improve the self-esteem of a young girl who matures into womanhood. METHODS AND RESULTS: A systematic review of literature was performed through electronic database searches (Pubmed, Medline and Embase). Studies published in English-language, peer-reviewed journals from 1996 to 2013 were included. The selected studies focused on the risk factors, the unique features and treatment options of the PCOS in puberty. The pathogenesis of the PCOS was hypothesized to be based on interactions between genetic and certain environmental factors. The diagnosis was usually difficult in young girls. The syndrome was related to a greater risk of future infertility, type II diabetes mellitus, the metabolic syndrome and cardiovascular disease. Early treatment was crucial to prevent the long-term complications of the syndrome, especially infertility and cardiovascular disease. DISCUSSION: The recognition of the early signs of PCOS during or even before adolescence is of great importance. It is essential to establish the correct diagnosis for PCOS and rule out other causes of androgen excess in young women with hyperandrogenism. The type of treatment applied should be considered on an individual basis. ABBREVIATIONS: PCOS = Polycystic Ovary Syndrome.

Laparoscopic treatment of 1522 adnexal masses: an 8-year experience.

Objective. To reevaluate the long-term effectiveness and safety of laparoscopy in benign ovarian pathology. Materials and Methods. 1522 women with benign adnexal cysts, laparoscopically treated in the 3rd Department of Ob/Gyn, General University hospital "Attikon" and "Lito" Maternity Hospital between July 1998 and December 2006, were included. Results. The diagnosis in 1222 (80,6%) cases was endometriosis of the ovary, 60 (4%) hydrosalpinx, 51 (3,3%) serous cystadenomas, 44 (2,9%) dermoid ovarian cyst, 38 (2,5%) borderline tumors, 35 (2,3%) unruptured follicles, and 33 (2,2%) paraovarian cysts. In 174 cases (11,5%) laparoscopy was converted to laparotomy due to technical difficulties or suspicion of cancer. In particular, laparotomy was performed in 119 (8%) women due to severe adhesions and 18 (1,2%) women due to bleeding that could not be controlled safely by laparoscopy. In 36 (2,4%) women frozen section during operation revealed malignancy and laparoscopy was converted to laparotomy. A few operative complications were recorded like post-op fever, small hematomas at the trocar entries. Conclusions. Laparoscopic surgery seems to offer significant advantages such as reduced hospital stay, less adverse effects, better quality of life, and superior vision especially on surgical treatment of cases like endometriosis.

Breast conserving surgery in multicentric breast cancer, preliminary data of our experience.

INTRODUCTION: It is widely supported that multicentric disease of the breast (MCDB) is a contraindication of breast conservative surgery (BCS). MATERIALS AND METHODS: This is a multicentric study (two breast cancer units from Greece, one from France) involving patients with at least two primary tumors in separate quadrants of the breast and no diffuse suspicious microcalcifications on mammography. Sixty-one patients were included in the study, but 49 were followed up to the end. Patients were randomly assigned in total mastectomy (TM) and BCS groups. End point of the study was disease-free survival rates three and five years after initial operation. RESULTS: Three years after BCS, local recurrence (LR) was observed in two patients (7%) and one after five years (total recurrence rate: 11%). A TM was performed in these patients, and in two there was no LR or distant metastasis (DM) five years after. The third patient was disease free two-years later. Three years after TM, eight patients (36.4%) had DM and 14 (63.6%) did not (p = 0.004). Five years after TM, eight patients (36.4%) had DM and 14 patients (63.6%) di not (p = 0.03). CONCLUSION: The results showed that conservative surgery was an alternative surgical option in multicentric breast cancer with good results regarding disease-free survival and recurrence.

Improving ductoscopy with duct lavage and duct brushing.

AIM: To assess the combined technique of duct lavage (DL) and duct brushing (DB) performed during ductoscopy in pathological nipple discharge (PND). MATERIALS AND METHODS: The study was conducted in two hospitals: Rea (Greece) and in Meet Ghmmr Oncology Center (Egypt), from January 2011 to April 2013. Sixty-four women were enrolled. A sample of cells was collected with the use of DB. Afterwards, DL was performed. For each case, liquid cytology was compared to the final histology. RESULTS: From the 19 histological diagnosis of duct ectasia, cytology by DL plus DB (CDLDB) was correct in 17 cases (89.5%). For 28 papillomas, CDLDB was correct in 19 cases (67.9%). For breast cancer (six cases), CDLDB was correct in five cases (83.3%). Also, CDLDB found 45.5% of miscellaneous benign cases. In total, cytology performed by CDLDB was correct in 46 of 64 patients: 71.9%. Thus, the sensitivity of CDLDB ranged from 67% to 90%, depending on the histological diagnosis. CONCLUSION: This technique showed a high accuracy, in contrast to other studies that used only DL.

Tomosynthesis improves breast cancer detection: our experience.

Breast tomosynthesis (BT) is a novel imaging technology in which an x-ray fan beam sweeps in an arc across the breast, producing tomographic images and it can reduce tissue overlap encountered in conventional two-dimensional (2D) and thus has the potential to improve detection of breast cancer and facilitate accurate differentiation of lesion types. The purpose of this article was to assess the positive predictive value (PPV) of breast cancer with BT versus full-field digital mammography (FFDM) and the assessment of detec- tion of both techniques in the present series.

The relationship between Anti-Müllerian hormone and other reproductive parameters in normal women and in women with polycystic ovary syndrome.

OBJECTIVE: To correlate Anti-Müllerian hormone (AMH) levels with years since menarche as well as to investigate the AMH relationship with ovarian morphology and levels of androgens in healthy normo- ovulatory women and in women with polycystic ovary syndrome (PCOS). DESIGN: Prospective clinical study. SETTING: University Hospital of Alexandroupolis, Lito Maternity Hospital. PATIENTS: Forty two healthy normo-ovulatory women and sixty one women with PCOS, recruited on the basis of the classic PCOS criteria (Rotterdam consensus meeting definition of PCOS (ESHRE/ASRM, 2004). INTERVENTIONS: Fasting blood was obtained from all subjects in the early follicular phase (days 5-6) after spontaneous or induced menses (in PCOS), and transvaginal ultrasound examination was performed. MAIN OUTCOME MEASURES: Assessment of values for follicular stimulating hormone (FSH), testosterone (T), AMH, as well as assessments of years since menarche and ovarian volume. RESULTS: AMH had a statistically significant positive correlation with the ovarian volume (r =0,623, r =0,579 P<0.01) and negative correlation with years since menarche (r =-0,766, r =-0,796 (P<0.01). In women with PCOS, AMH and years since menarche had a significant correlation with testosterone (r =0,477, r = -0,527, P<0.01) CONCLUSIONS: This study underlines the relation between AMH and years since menarche as well as the AMH differences in relation with certain clinical or endocrine characteristics between normal and PCOS women.

Sentinel lymph node detection by intranipple injection of patent blue dye in breast cancer: a preliminary report of a feasibility study.

Sentinel lymph node (SLN) biopsy is a well established option for assessing axillary lymph node status in breast cancer. Several techniques have been applied so far (superficial or deeper ones). Based on anatomical features of the lymphatic drainage in the breast, we assessed the feasibility of an intranipple approach for SLN mapping. Our data support the feasibility of SLN detection by our technique, with a high rate of SLN identification, which could be used in clinical practice as an alternative to the peri-areolar approach.

Chlamydial infection in female lower genital tract and its correlation with cervical smear abnormalities.

BACKGROUND: It is widely known that infection by Chlamydia trachomatis (CT) is the most common curable sexually transmitted infection (STI) among the young population.Chlamydial cervicitis has been suspected in the past to be a risk factor for squamous intraepithelial neoplasia (SIL) and cervical cancer on the basis of case-control comparisons of serological tests. METHODS: A total of 110 women with symptomatic cervicitis were examined and samples for microbiologic detection of Chlamydia trachomatis antigen were obtained. Colposcopic, cytologic and microbiologic analyses were performed. All results were statistically analysed and correlated. RESULTS: 41 patients (37.2 %) were found positive for Chlamydia trachomatis antigen (Group I) and 69 patients (62.8 %) were negative for Chlamydia trachomatis antigen (Group II). When compared to group II, the chlamydia-infected group I of women presented a larger percentage of dyspareunia (60 %), and the dysuric complaints were more common. The chlamydia-positive group revealed a higher incidence of atypical squamous metaplasia (52.5 % vs 27.9 %). Among the women with positive ELISA for chlamydia, a higher percentage of low-grade SIL was observed (6.3 % vs 3.6 %). CONCLUSIONS: Chlamydial infection, especially chlamydial cervicitis occurs often among young women of reproductive age. In these women, a good clinical assessment is necessitated including previous clinical history record, as well as detailed microbiologic, cytologic and colposcopic evaluations (Tab. 5, Ref. 19).

Lymphedema of the arm after surgery for breast cancer: new physiotherapy.

Secondary lymphedema of the upper limb is a complication which can be found in patients who have undergone surgical breast cancer treatment with an axillary dissection. Lymphedema following breast cancer treatment remains a long-term disabling complication which cannot be treated in a decisive and radical manner. The objective of the treatment is to limit complications, to try to preserve the remaining lymphatic system and to develop new anastomosis. It consists of a specific decongestive physiotherapy, which may include a specific lymphatic drainage and skin mobilization, reducing bandages including Mobiderm (Thuasne), and sub-bandage muscular exercises. However variations in the therapy have been recorded by different teams. Our experience in treating lymphedema in Tunisia takes into consideration the epidemiological, climatic, cultural and socio-economic conditions of the country. The difference in our treatment compared to what is being advocated elsewhere essentially consists of the no muscular exercise while wearing a bandage. This is compensated for by daily domestic activities, by prolonging the first two phases of treatment (the intensive phase and the stabilization phase), and by the use of the hydro gel dressing Hydrosob (Hartmann) to prevent blisters induced by the pressure imposed by Mobiderm studs of the bandage on the skin, and also by the superimposition of two types of Mobiderm bandages (small and large blocks).

The role of oral contraception use in the occurrence of breast cancer. A retrospective study of 405 patients.

UNLABELLED: The investigation of potential predisposing factors of breast cancer, a disease accounting for almost one-third of malignancies in women, is necessary in order to reduce the incidence. MATERIALS AND METHOD: We interviewed 405 female patients who had been diagnosed with breast cancer and who also reported having used oral contraceptive pills before. They were categorized into two groups (group A < 7 years OC use and group B > 7 years OC use). RESULTS: Statistical analysis revealed a small (p < 0.02) but significant increased risk of the disease to BRCA mutation carriers, as well as to the women with a significant medical or family history of breast, ovarian or colon cancer who had also previously used oral contraceptive pills for more than seven years. DISCUSSION: Breast cancer seems to be positively dependent on prolonged oral contraceptive use. CONCLUSION: More research is needed to establish the hypothesis that the human genome is vulnerable to oral contraceptives.

Quantitative assessment of breast mammographic density with a new objective method.

Women with increased mammographic density (MD) have an increased risk of developing breast cancer. The purpose of our study is to evaluate an experimental method to quantify MD using a program (compatible with Windows XP, Vista and 7) which measures black areas as 0, white areas as 100 and grey scale areas with intermediate values between 0 and 100, depending on the "density" of the area. Digital screening mammograms were directly estimated with this method. Initial idea and steps of the program were based on a Mac utility used by our research team.

Conservative surgery for borderline ovarian tumors--emphasis on fertility preservation. A review.

BACKGROUND: Borderline ovarian tumors account for 15-20% of all ovarian epithelial tumors. Since their original description in 1929, our knowledge of their natural history and molecular pathology has advanced most dramatically over the last two decades. This improved knowledge of BOT has permitted to drastically decrease the therapeutics of these tumors, which remains mostly surgical. METHOD: We studied the available literature on surgical management of BOT accentuating the most important aspects on this topic: radical vs. conservative treatment, fertility preservation. RESULTS: Although there are conflicting reports about some of the aspects of surgical management of these tumors, since BOTs commonly affect women of reproductive age, who have not completed childbearing, have an excellent overall prognosis and the majority of them (approximately 50% to 85%) are stage I at diagnosis, conservative surgery (unilateral salpingo-oophorectomy or cystectomy) can be safely performed after comprehensive surgical staging, in order to preserve fertility. CONCLUSION: Conservative surgery could be safely performed in young patients treated for BOT, provided that they are carefully followed-up.

Complementary treatment with oral pidotimod plus vitamin C after laser vaporization for female genital warts: a prospective study.

This is a prospective study to assess a complementary treatment for genital warts after laser vaporization. 62 patients were enrolled in two randomized groups: Al: laser vaporization alone. A2: laser vaporization, followed with Pidotimod plus vitamin C for 2 1/2 months. The latter treatment shortened the time of warts remission and marginally decreased the rate of the warts' recurrence: 81% versus 67% (N.S.). Despite the non-significant difference, this complementary treatment seems to have some efficiency.

Preliminary results of objective assessment of mammographic percent density.

Breast density assessments performed by using the Breast Imaging Reporting and Data System (BI-RADS) have been completely qualitative and the American College of Radiology (ACR) fibroglandular density descriptors are mainly subjective. However, women with increased mammographic density (MD) have an increased risk of developing breast cancer. The purpose of our study was to evaluate an experimental method to quantify MD using a software utility which measures absolutely black areas as zero and absolutely white areas as 100. In grey scale areas, these values range between 0 and 100, depending on the "density" of the area. Digital screening mammograms were directly estimated with this method. We concluded that there is a significant correlation between ACR quartiles and this grey scale percentage method, although several improvements on the original idea are planned.

Maximizing the benefits of screening mammography for women 40-49 years old.

BACKGROUND: While women aged 50 and older are broadly considered to benefit from screening mammograms, the evidence of any similar advantages for younger women are still considered insufficient to form any substantial conclusions on the matter. The primary goal of this study was to examine whether or not the mortality rate of younger women is benefited by mammography, and if so, how can this beneficial effect be maximized. METHODS: The authors have taken into account all available randomized control trials (RCTs) and have conducted a meta-analysis based on those RCTs to study the effect of mammography on the mortality rate of women younger than age 50. Further interpretation on various aspects of the results has also led to separate meta-analyses, with the RCTs included grouped in accordance to the mean time interval between screening mammograms employed by each study. The findings and conclusions of the comparison were used to calculate the number of mammograms necessary to reduce the absolute death risk, depending on the time interval between screening mammograms. RESULTS: The meta-analysis indicated a reduction in breast-cancer mortality in the intervention group, which reached statistical significance (relative risk (RR) 0.81 [95% CI 0.71-0.93] p < 0.01). Furthermore, when the RCTs included were grouped according to their mean time interval between mammograms, there was a definite increase of statistical significance in favor of those RCTs with shorter interval times (RR 0.76 [95% CI 0.64-0.89] p < 0.01). CONCLUSIONS: The significant mortality rate reduction demonstrated by the meta-analytical results is a key indicator of the beneficial effect of mammography on the age group of women younger than 50. Additionally, the increase in the aforesaid significance when combining RCTs with short time intervals between mammograms, as opposed to those RCTs with longer intervals, suggests that the optimal use of mammographic screening lies with the former. This is better demonstrated when taking in account our approach to answering the practical question of "how many screening mammograms will take to save one life?" in correlation with the mean time interval involved.