Management of cervical cancer during pregnancy.

Cervical cancer (CC) is the most common gynaecological cancer during pregnancy. The rarity of the disease and lack of randomised control studies have prevented the establishment of treatment guidelines. The management of CC mainly follows the guidelines for the non-pregnant disease state, expert opinions and limited case reports. Although the management of CC diagnosed during pregnancy appears to be a significant dilemma for the patients and specialists, the prognosis of CC is not influenced by pregnancy. The treatment decision should be made collaboratively with a multidisciplinary team consisting of an obstetrician, gynaecologist, oncologist and paediatrician. The concerns of the patient should be taken into account.

Stage-III and -IV endometrial cancer: A single oncology centre review of 104 cases.

The objective of this study was to evaluate the clinicopathological characteristics, treatment and prognosis of advanced endometrial cancer (EC). Patients who underwent surgery for advanced EC between January 1995 and December 2012 were retrospectively reviewed. Patients with missing data, concurrent cancers or uterine sarcomas and those who did not undergo surgery were excluded. The effects of clinicopathological factors on progression-free survival (PFS) and overall survival (OS) were analyzed. A total of 104 patients were included. Most presented with endometrioid histology (74%) and stage-III disease (87.5%), and 76.9% underwent optimal cytoreduction. A multivariate analysis confirmed that lymphovascular space invasion (LVSI) is an independent poor prognostic factor for PFS [odds ratio (OR): 21.37, p = 0.005] and OS [OR: 8.09, p = 0.044]. Suboptimal cytoreduction is another independent poor prognostic factor for PFS [OR: 5.68, p < 0.001]. Our study demonstrated that LVSI and optimal cytoreduction are the most significant factors affecting the survival of advanced EC patients.

Surgical management of intrauterine devices migrated towards intra-abdominal structures: 20-year experience of a tertiary center.

AIMS: To share surgical management experiences of intra-abdominal intrauterine devices (IUDs) in tertiary center. MATERIAL AND METHODS: A total of 27 patients were retrospectively analyzed. This retrospective study was conducted between September 1992 and April 2013 at Department of Obstetrics and Gynecology Tepecik Research and Training Hospital, Izmir, Turkey. Demographic findings, diagnostic methods, and operative notes of patients were obtained from the patient file. FINDINGS: Of the 27 IUDs, nine (33.3%) were in omentum, four (15%) were in Douglas pouch, one in left sacrouterine ligament, one in uterovesical space and one in fundus posterior, six (22%) in left adnexial region, one in abdominal wall, one was subdiaphragmatic, one in ligamentum latum, and one in jejunum. Almost all of the patients had TCu-380 A IUDs. Seventeen patients (63%) were managed by laparoscopy, whereas laparotomy was required in ten (37%). Adhesions were found in 23 of 27 (85%) patients with varying degrees. In four cases the incision was extended due to adhesions. CONCLUSION: A missing string was the first finding of an intra-abdominal IUD. Pelvic ultrasonography, X-ray, and hysteroscopy methods should be performed in order to detect the localization of IUD in case of a missing string. Surgical approach should be the first treatment option for intra-abdominal IUDs.

Comparison of the histopathological diagnoses of preoperative dilatation and curettage and Pipelle biopsy.

PURPOSE: To evaluate the accuracy of dilatation and curettage (D&C) and Pipelle biopsy for the diagnosis of endometrial pathologies and determine whether the amount of endometrial tissue obtained using these techniques is sufficient for further histopathology of hysterectomy specimens. MATERIALS AND METHODS: Patients undergoing hysterectomy for various indications were evaluated via Pipelle endometrial biopsy or D&C from 2009-2011. A total of 267 women were included with 78 women enrolled in the Pipelle group and 189 in the D&C group. Uterine findings were grouped as normal, hyperplasia, focal lesion, atypia, and atrophy. Histological sections from the Pipelle biopsy or D&C specimens were compared to each other and hysterectomy specimens. RESULTS: The concordance rate between Pipelle biopsy and hysterectomy was 62% and between D&C and hysterectomy was 67%. The sensitivity of Pipelle biopsy and D&C for detecting hyperplasia was 41.7% and 45%, respectively, and for detecting atypia was 71.4% for both techniques. The sensitivity of detecting atrophic endometrial tissue was significantly higher in the D&C group at 80% compared to 37.5% in the Pipelle biopsy group (p = 0.030). All other parameters were similar in both groups. CONCLUSION: Pipelle biopsy and D&C were equally successful for diagnosing endometrial pathologies. Neither Pipelle biopsy nor D&C was adequate for detecting focal endometrial pathologies and endometrial hyperplasia. In contrast, both techniques were sufficient for the diagnosis of atypia. The Pipelle biopsy technique is a reasonable pre-hysterectomy procedure that is more economical, less invasive, and can easily be performed in multiple clinics.

Primary retroperitoneal mucinous cystadenocarcinoma during pregnancy.

Primary retroperitoneal mucinous cystadenocarcinoma (PRMC) is an extremely rare tumour. This case report describes the treatment and prognosis of a patient with PRMC during pregnancy. This is the third case of PRMC in a pregnant woman, worldwide. The patient was a 37-year-old woman presenting with a left mid-abdominal and pelvic semisolid, cystic mass at 29 weeks' gestation. At 30 weeks' gestation, she underwent an exploratory laparotomy, which revealed a solid tumour (22 × 13 × 11 cm) with an intact capsule extending from the inferior pole of the left kidney to the pelvic inlet in the left retroperitoneal area. The tumour had adhesions with the surrounding connective tissue and could be excised with its capsule intact. In conclusion, based on the limited information available, a PRMC with no visible dissemination excised with an intact capsule appears to have a good prognosis. Tumour excision may be adequate for treatment of PRMCs in the extragenital space and with no dissemination.

What Are the Risk Factors for Lymphocyst Formation Apart From Lymphnode Dissection and Lymphnode Count in Gynecologic Malignancy?

Aim: Lymphocyst is one of the most common complications of lymphadenectomy and generally encountered during uro-gynecological oncology surgeries. We aimed to define the risk factors for formation of a lymphocyst in patients with various gynecological cancer types in whom a lymphadenectomy was performed. Methods: This retrospective study was performed on 206 patients. Of the 206 patients, 100 were diagnosed with a lymphocyst, and 106 were assigned to a control group. Laboratory findings and surgical characteristics of the patients were compared. Results: No differences were observed in age, pre-operative hemoglobin; platelet, white blood cell, and lymphocyte counts; or pre-operative albumin level (p = 0.315, 0.500, 0.525, 0.683, 0.740, and 0.97, respectively). A significant effect of the heparin dose × heparin days interaction and lymphocyst formation was observed (p = 0.002). Lymphocysts were most frequently detected in the ovarian cancer subgroup (49 %). Significant differences were detected between the groups in the percentages of patients who underwent CT only and RT only treatments (p = 0.001 and 0.002, respectively). The logistic regression analysis revealed a relationship between the LMWH dose × days interaction and formation of a lymphocyst (OR, 1.10; 95 % CI, 1.0-1.13; p = 0.01). Conclusion: The association between total LMWH dose administered and the formation of lymphocysts in patients with gynecological pelvic cancer was investigated for the first time. Significant relationship between heparin dose × days and lymphocyst formation was found. Although anticoagulation with LMWH is essential for preventing thromboembolism, it should be used appropriately to prevent other complications, such as bleeding and lymphocysts.

The role of hypoxia related angiogenesis in uterine smooth muscle tumors.

Mechanisms of hypoxia-related angiogenesis are important for uterine smooth muscle tumors. Factors that are related to angiogenesis during hypoxia include vascular endothelial growth factor (VEGF), hypoxia inducible factor 1α (HIF1α), T-cell intracellular antigen1 (TIA1), eukaryotic translation initiation factor 2α (eIF2α) and thrombospondin 1 (TSP1). We investigated immunoreactivities of VEGF, HIF1α, TIA1, eIF2α and TSP1 using an indirect immunoperoxidase method for formalin fixed, paraffin embedded tumors that had been diagnosed as leiomyoma (LMY), cellular leiomyoma (CLM) or leiomyosarcoma (LMS). TSP1 immunoreactivity was scored as moderate, mild or minimal, while VEGF, eIF2α and TIA1 immunoreactivities were scored as mild, moderate and strong in LMY, CLM and LMS samples, respectively. HIF1α immunoreactivity was scored as mild to minimal in LMY, CLM and LMS samples, but showed no statistically significant differences among samples. Although angiogenic factors showed strong immunohistochemical staining intensity in LMS, anti-angiogenic factors showed minimal immunohistochemical intensity. There was no difference in HIF-1α immunoreactivity compared to LMY, CLM and LMS samples. We suggest that HIF1α protein synthesis could be suppressed by eIF2α and TIA1. Furthermore, VEGF could be activated by pathways such as COX2, Ras, NF-ĸB or c-myc instead of HIF1α. Angiogenesis could trigger and accelerate tumor development; therefore, anti-angiogenic therapy could be useful for treatment of tumors.

Immunolocalizations of VEGF, its receptors flt-1, KDR and TGF-beta's in epithelial ovarian tumors.

OBJECTIVE: Angiogenesis is an essential factor for growth, differentiation, invasion and metastasis of tumors. In this study, we aimed to evaluate the immunolocalizations of vascular endothelial growth factor (VEGF), its receptors flt-1, KDR/flk-1, and transforming growth factor-beta's (TGF-beta) in epithelial ovarian tumors, utilizing indirect immunohistochemistry to understand the role of the angiogenic events in ovarian neoplasia. METHODS: Tissue blocks from 40 patients who had ovarian pathology (borderline serous-mucinous tumor and malignant serous-mucinous adenocarcinoma of the ovary) were included in this study. All formalin-fixed, paraffin-embedded tissue sections were stained with hematoxylin-eosin or primary antibodies against VEGF, flt-1, KDR/flk-1, TGF-beta1, TGF-beta2 and TGF-beta3 using the avidin-biotin-peroxidase method. H-SCORE, a semi-quantitative grading system, was used to compare immunohistochemical staining intensities. RESULTS: Positive VEGF immunoreactivity was concentrated in the epithelial and stromal parts of all the ovarian samples and the endothelial cells in the stroma were also stained. Increased immunoreactivity of VEGF was observed in malignant ovarian adenocarcinomas compared to the borderline tumors of the ovary. VEGF receptors, flt-1 and KDR/flk-1 immunoreactivities were detected not only in vascular endothelial cells, but also in tumor cells at malignant sites. Immunoreactivities of VEGF and its receptors were coexpressed in tumor cells of the ovarian carcinoma. While immunoreactivities of TGF-beta1 and TGF-beta2 were both overexpressed in malignant ovarian carcinomas, immunoreactivity of TGF-beta3 was still mild. CONCLUSION: Our results suggest that overexpression of VEGF, its receptors flt-1, KDR/flk-1 and TGF-beta interaction may play an important role in the ovarian cancer biology, with potential effects on tumor growth and angiogenesis. New therapeutic strategies using VEGF and TGF-beta antagonists could obtain an additional approach to the treatment ovarian carcinoma by inhibiting angiogenesis.

Development of uterine sarcoma after tamoxifen treatment for breast cancer: report of four cases.

Tamoxifen (TAM) is widely used in the treatment of breast cancer, and its paradoxical effects on female genital system are well known. During the past 10 years, many descriptions of nonepithelial uterine malignancies related to long-term TAM usage have been reported in the literature. Four uterine sarcoma patients who had history of TAM usage for previous breast cancer are presented in this study. The mean time of exposure to TAM was 6 (range 3-11) years, and the mean cumulative dose of drug was 43.82 g. All patients were postmenopausal, and the mean age was 66 (range 61-73) years at the time of the diagnosis of the uterine malignancy. Two (50%) patients had uterine malignant mixed müllerian tumor, and two (50%) had leiomyosarcoma. In one (25%) patient was diagnosed with endometrial biopsy made for a postmenopausal vaginal bleeding; the others (75%) were asymptomatic and their diseases were diagnosed during the pelvic examination and transvaginal ultrasonography. All patients underwent surgery +/- adjuvant therapy (chemotherapy and/or radiation therapy), and two (50%) patients died because of the sarcoma. In consequence, early detection of TAM-related uterine sarcoma is required for orderly gynecological examination in patients having history of TAM usage for previous breast cancer.

A randomized prospective study of comparison of reservoir ports versus conventional vascular access in advanced-stage ovarian carcinoma cases treated with chemotherapy.

Vascular access ports were developed to overcome many of the problems associated with limited peripheral access, combined with the need for frequent venipuncture, in oncology patients receiving long-term intensive therapy. In this study, we compared the effectivity and acceptability of vascular access port with conventional needle application together with complication rates in ovarian cancer patients. Advanced-stage ovarian carcinoma cases under chemotherapy treatment were equally randomized into two groups, implantable vascular access ports applied to one group (22 cases) and conventional vascular access applied to the other (38 cases) as a control group. Anteroposterior thoracic X-rays of implantable port-applied cases were taken before and after the application. Vortex reservoir ports (Horizon Medical Products, Inc., Manchester, GA) were used in the application to the subclavian vein. Classic peripheral venipuncture method (Medikit), Mediflon(trade mark) IV cannula with PTFE radiopaque catheter and injection valve, Eastern Medikit Ltd, Gurgaon, Haryana, India) was used in the control group. Vascular accesses of all cases were controlled just after the application, 12 h after the application, and during each drug or intravenous fluid application. Mean port insertion time was 26.3 min. Total port occlusion was observed in two of the port-applied cases (11.7%) and partial port occlusion was observed in five of the port-applied cases (29%). Heparin and saline combination was used in order to open the port tip, in five cases, two with total occlusion and three with partial occlusion. Infection was observed in only one case (5%) to whom appropriate therapy was given, and the port was taken out. Ports of two cases were also taken out because of skin dehiscence. No change in port tip position was observed in any of the cases. Total occlusion was observed in 16 of the 38 cases (42.1%) with conventional vascular access. In 12 cases (31.5%), a need arose to change the conventional vascular access. No vascular access was found in 13 of the 38 cases (34.2%). Application of reservoir ports especially to cases with advanced-stage carcinomas, under chemotherapeutic drug treatment, leads to minimal anxiety for the patient and his/her family and minimal risk of physical trauma to the patient with only one vascular access. Reservoir ports occlude or cause infection to a lesser extent than classic vascular access methods. Occlusion or infection rates of reservoir ports are statistically significant, lower than those of classic venipuncture.