Hysteroscopic Transcervical Resection for Atypical Polypoid Adenomyoma of the Uterus: A Valid, Fertility-Preserving Option.

STUDY OBJECTIVE: To evaluate hysteroscopic transcervical resection (TCR) for atypical polypoid adenomyoma of the uterus (APA). DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Single tertiary hospital. PATIENTS: Women who underwent TCR for APA at Kawasaki Municipal Hospital between 2003 and 2015. INTERVENTIONS: Clinical records were obtained. MEASUREMENTS AND MAIN RESULTS: Thirty-five patients with APA were evaluated. The median patient age was 35 years (range, 23-43 years), and the median tumor diameter was 22 mm (range, 9-51 mm). The median duration of observation after the first TCR was 34.0 months (range, 4.2-133.7 months). In 19 patients, the tumor recurred after the first TCR. A second TCR was performed in 13 patients, 11 of whom experienced recurrence. A third TCR was performed in 7 patients, all 7 of whom experienced recurrence. A fourth TCR was performed in 4 patients, 3 of whom experienced recurrence. The recurrence rate after the second TCR was higher than that after the first TCR (71.4%-84.6% vs 54.3%; p < .01, t test). The median disease-free interval was 12.4 months after the first TCR, 15.3 months after the second TCR, 10.5 months after the third TCR, and 10.9 months after the fourth TCR. Seven patients progressed to endometrial cancer; however, there was no mortality. Six of the 35 patients conceived, and 4 had a normal spontaneous delivery. CONCLUSION: Owing to disease-free intervals that follow treatment, TCR is a promising treatment modality as a fertility-preserving option for patients with APA under careful observation. Twenty percent of patients with APA develop cancer; however, the present study showed no mortality.

Seek and ye shall find: the importance of careful macroscopic examination and thorough sampling in 2522 cholecystectomy specimens.

Gallbladder dysplasia and carcinoma (GBDC) vary greatly in incidence worldwide. We aimed to determine their prevalence in an Irish population, to assess the influence of tissue sampling protocols upon GBDC diagnosis, and to correlate various macroscopic and microscopic features with GBDC. We retrospectively reviewed histology reports of cholecystectomy specimens accessioned from 2000 to 2013. A total of 2522 cholecystectomy reports were reviewed, from 1860 female and 662 male patients. Male patients were significantly older (54.8 vs 46.8 years). There were 29 cases of dysplasia (1.15%) and 12 cases of carcinoma (0.48%), of which 10 were primary gallbladder cancers (0.4%). In 83.4% of cases, there was pathologic or radiologic evidence of cholelithiasis. Histologic findings included chronic (91.1%) or acute (15.4%) cholecystitis, cholesterosis (10.9%), adenomyomatous hyperplasia (2.1%), xanthogranulomatous inflammation (2.02%), and "porcelain" gallbladder (0.2%). Patients with GBDC were more likely to have a macroscopically identifiable lesion (29.4% vs 1.8%, positive predictive value, 18.18%, negative predictive value, 99.03%). Gallbladder dysplasia and carcinoma patients also had larger gallstones (median, 19 vs 12 mm) and were more likely to have adenomyomatous hyperplasia (8.8% vs 2.05%). When cases with a macroscopically identifiable lesion or clinical details suggestive of a gallbladder tumour were excluded (n = 2385), GBDC was significantly more frequently diagnosed if multiple tissue blocks had been sampled (2.91% vs 0.76%; relative risk (RR), 3.836). Rates of GBDC in Irish cholecystectomy specimens are low. The absence of a macroscopically identifiable lesion has a high (but not 100%) negative predictive value for GBDC. Sampling with more than 1 block significantly increases pickup rates of GBDC in these cases.

An unusual association of diffuse adenomyomatosis with dysplastic adenoma in chronic calculous cholecystitis: case presentation.

BACKGROUND: Gallbladder adenomyomatosis is an epithelial proliferation and hypertrophy of the muscularis mucosae of the gallbladder. Rokitansky-Aschoff sinuses are a characteristic of this condition. The segmental adenomyomatosis has a higher risk of developing into gallbladder carcinoma, especially in the fundal region of elderly patients.We report the case of a patient affected by chronic calculous cholecystitis with diffuse adenomyomatosis associated with dysplastic adenoma. CASE PRESENTATION: An 81-year-old woman presented at our hospital with a 1-year history of intermittent pain localized at the right upper abdominal quadrant, without diffusion to any other body part. On physical examination the abdomen was soft, not distended, and tender to palpation in the right upper quadrant. Murphy sign was negative. Laboratory tests were normal. The patient was scheduled for a laparoscopic cholecystectomy, and neither endoscopic ultrasonographic scan nor magnetic resonance imaging was performed. The operation, performed after obtaining informed consent, was uncomplicated and the intra-operative pathological examination showed no malignancy. The definitive pathological examination of the gallbladder showed: multiple stones of cholesterol origin; diffuse mucosal adenomyomatosis; and a 1.1 cm pedunculated mass localized at the fundus, whose surface was lumpy. This mass was diagnosed as an adenoma with multiple areas of severe dysplasia. CONCLUSIONS: The adenoma of the gallbladder, together with the dysplasia, represents a biological carcinogenetic model. Carcinoma has rarely been reported in adenomyomatosis. Degenerative risk suggests surgery should be mandatory when there is a concomitant presence of large adenoma and adenomyomatosis.

[Gallbladder adenomyomatosis].

THE AIM: to familiarize with the main clinical aspects of the adenomyomatosis gallbladder. Recent literature data show that adenomyomatosis of the gallbladder is not a rare disease and its frequency in cholecystectomy is 2-8.7%. It is more common after the age of 35-40 years and among women. Course of the disease is complicated by cholecystolithiasis, and localization in the bottom of the gall bladder-malignization. The main method of diagnosis is ultrasonography. For the differential diagnosis of cancer of the gall bladder used under the MRIs. Cholecystectomy is indicated for complications of cholecystolithiasis and suspected malignancy in the gallbladder.

Genetic variation in base excision repair genes and the prevalence of advanced colorectal adenoma.

Base excision repair (BER) corrects DNA damage caused by oxidative stress and low folate intake, which are putative risk factors for colorectal neoplasia. To examine the relationship between genetic variation in BER genes and colorectal adenoma risk, we conducted a case-control study of 767 cases of advanced colorectal adenoma and 773 controls from the baseline screening exam of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Cases included participants diagnosed with advanced left-sided adenoma, and controls were subjects without evidence of a left-sided polyp by sigmoidoscopy, frequency-matched to cases on race and gender. Twenty single nucleotide polymorphisms were genotyped in four BER genes (APEX1, PARP1, POLB, and XRCC1), and conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for the association with colorectal adenoma. Two variants with possible functional significance were associated with risk. The APEX1 51H variant was associated with a borderline significant decreased risk of colorectal adenoma (OR, 0.66; 95% CI, 0.44-1.00), and the XRCC1 399Q variant was inversely associated with risk among Caucasians (OR, 0.80; 95% CI, 0.64-0.99). Homozygotes at two PARP1 loci (A284A and IVS13+118G>A) were also associated with a decreased risk of colorectal adenoma compared with wild-type carriers (OR, 0.70; 95% CI, 0.49-0.98 for both), which was restricted to advanced adenomas displaying histologically aggressive characteristics (OR, 0.51; 95% CI, 0.33-0.78, P = 0.002 for PARP1 A284A). This study suggests that polymorphisms in APEX1, XRCC1, and PARP1 may be associated with advanced colorectal adenoma.

Clinical presentation and management of atypical polypoid adenomyomas: Systematic review of the literature.

The aim of this study is to investigate clinical behavior of Atypical Polypoid Adenomyomas (APAs) and to describe the rates of (i) recurrences, (ii) their association with endometrial hyperplasia and (iii) with endometrial cancer. All studies that reported the outcome of the clinical management of patients with histologically proven APAs were included. A review of the English literature since 1970 was systematically performed (PROSPERO No CRD42018080003). A quality assessment tool was used to assess the scientific value of all the studies. Main contribution of this review is the proposal of new definitions regarding the clinical behaviour of APAs: Cure, Residual or persistent APA, Recurrent APA, Synchronous endometrial hypeprasia, Subsequent endometrial hyperplasia, Synchronous endometrial cancer, and Subsequent endometrial cancer, are terms elucidated in the context of this review. Their rates after initial diagnosis and treatment of APAs are presented as the main outcome measures. 63 studies and 350 patients were included in the systematic review. Fifteen studies that reported 208 patients who did not have hysterectomy as initial treatment were included for further quantitative assessment. The cure rate of APAs in cases where uterus was preserved was 51.0% (106/208), the residual rate of APA was 20.2% (42/208), the recurrence rate of APA was 35.1% (73/208), the concurrent endometrial hyperplasia rate was 7.2% (15/208), the concurrent endometrial cancer rate was 4.8% (10/208), the subsequent endometrial hyperplasia rate of was 6.7% (14/208), and the subsequent endometrial cancer rate of was 10.1% (21/208). Moreover, 56.4% of the patients with APA who opted for uterine sparing treatment and wished to conceive they had a viable pregnancy. The use of hysteroscopic techniques at the initial management of APAs is related with significantly decreased residual rate, and signicantly increased cure rates. In this review, the recurrence rate and the association of APAs with cancer appeared to be higher compared to the previously reported in the literature rates. APAs comprise an intriguing clinical entity that needs individualized treatment, considering the increased association to serious gynecological diseases. Hysterectomy is the appropriate treatment, however uterus-sparing surgery can be offered to selected patients.

Cystic uterine tumors.

BACKGROUND/AIMS: The differential diagnosis of cystic uterine tumors includes fibroids showing cystic degeneration, cystic adenomyomas, congenital cysts, and developmental anomalies. METHODS: The incidence, clinical presentation and accuracy in preoperative diagnosis of cystic uterine tumors were studied in a university hospital population over a 6-year period. RESULTS: 29 cases were included. Of these, 8 corresponded to the diagnosis of a non-fibroid uterine cystic enlargement, and 21 to that of a fibroid with cystic degeneration. Age and parity were significantly lower in patients with non-fibroid cysts. Rates of symptomatic women (60 vs. 55.6%) were similar in both groups. The preoperative diagnosis was accurate in 20/21 (95.2%) cases with a degenerated leiomyoma. On the contrary, in 6/8 (75%) cases with a non-fibroid cystic swelling an erroneous diagnosis of an adnexal or an extrauterine mass was made preoperatively. In this group, histology of the tumor showed a cystic adenomyoma in 3, a congenital cyst in 3, and a blind rudimentary uterine horn in 2 cases, respectively. CONCLUSION: Uterine cystic tumors are uncommon. Frequently, non-fibroid swellings are erroneously diagnosed as adnexal enlargements and their true origin only becomes evident during surgery.

Polycystic ovary syndrome and increased polyp numbers as risk factors for malignant transformation of endometrial polyps in premenopausal women.

OBJECTIVE: To determine the pre-malignant and malignant potential of endometrial polyps and to assess whether different clinical parameters are associated with malignancy in the polyps of premenopausal women. METHODS: The clinical records of operative office hysteroscopic and resectoscopic procedures for endometrial polyps in 417 premenopausal women who attended Baskent University were examined over a retrospective period of 30 months. Only premenopausal patients were included in the study. RESULTS: In 97.8% of women, histology showed benign endometrial pathology. In 2.2% of women, pre-malignant or malignant conditions were found in the polyp. Polycystic ovary syndrome (PCOS) and the presence of 2 or more polyps were associated with significant pre-malignant or malignant changes. CONCLUSION: The presence of irregular vaginal bleeding was not a predictor of malignancy in the polyp. Premenopausal women with PCOS and those with 2 or more polyps had an increased prevalence of polyp malignancy. These groups of patients, whether symptomatic or not, should be evaluated by hysteroscopic resection of the polyps.

[Anatomopathologic, clinical and radiologic aspects of benign tumors of the prostate in Mali, 759 cases]. / Aspects anatomopathologiques, cliniques et radiologiques des tumeurs benignes de la prostate au Mali, a propos de 759 cas.

The benign prostate tumours are dominated by prostatic adenomyoma. They are the first uro-genital pathology worldwide. The objective of this work is to describe the anatomo-pathological, clinical and radiological aspects of benign prostate tumours in Mali. It is a retrospective study which was conducted in Bamako (Mali) form January 1998 to December 2003. It has involved 759 patients who had histological confirmed prostate adenoma in the Department of Urology in Point G University Hospital. The patients were classified according to age, the clinical exam, the rate of prostate specific antigen (PSA), the sonogram, the macro and microscopic exam. The average age of the patients is 75.5 years. The apical part of the prostate is the area mostly involved. The adenomyoma is the most frequent histological type (98% of the cases). A very clear radiological and macroscopic disparity was noticed. "The night pollakiuria" was the primarily clinical sign in all patients; the prostate specific antigen (PSA) is high among more than 80%.

Black pigment gallstones with cholesterol gallstones in the same gallbladder. 13 cases in a surgical series of 1226 patients with gallbladder stones.

We studied 1312 consecutive patients who underwent surgery for gallstones in the biliary tract at one university hospital in Siena, Italy, with a systematic classification of gallstones found within the gallbladder. Of these patients, 1226 were found to have gallbladder stones; 94 of these had black pigment gallstones. Of these, 13 patients were found to have black pigment gallstones and cholesterol gallstones within their gallbladder. They all had multiple black pigment gallstones, usually very small (all < 6 mm diameter), in association with larger cholesterol stones in the gallbladder lumen. The cholesterol gallstones were single in seven cases, double in two cases, and multiple in four cases. All 13 of these patients with black pigment stones in association with cholesterol stones had histologic evidence of either adenomyomatosis or Rokitansky-Aschoff sinuses in the gallbladder wall. In nine of the 13 patients, the black pigment stones were located both in the gallbladder lumen and in close association with the gallbladder wall (in areas of adenomyomatosis or in Rokitanski-Aschoff sinuses). In the other four patients, the stones were found in close association with the gallbladder wall alone and not freely mobile within the gallbladder lumen. It is concluded that cholesterol stones and black pigment stones may be found in the same gallbladder. This association is infrequent with an incidence of 13 of 1226 (1.06%) in our series. There appears to be some relationship between the formation of the black pigment stones and the presence of adenomyomatosis or Rokitanski-Aschoff sinuses.(ABSTRACT TRUNCATED AT 250 WORDS)

Association between anomalous pancreaticobiliary ductal union and adenomyomatosis of the gall-bladder.

A frequent association of biliary tract carcinoma and anomalous pancreaticobiliary ductal union (APBD) is well recognized, especially gall-bladder carcinoma in undilated type APBD. However, little is known about the presence and incidence of adenomyomatosis (AMT) of the gall-bladder, a presumed premalignant lesion, in patients with APBD. This retrospective study was conducted to elucidate the clinical features and incidence of AMT in APBD patients with relation to undilated type and dilated type APBD. We reviewed the clinicopathological records of 30 patients with APBD (28 women and two men) encountered during the past 10 years. Among them, 22 patients underwent cholecystectomy and the resected specimens were subjected to histopathological examinations. Eleven cases of APBD patients were undilated type and 11 cases were dilated type. Adenomyomatosis was found in six (55%) of 11 undilated type and one (9%) of 11 dilated type, and fundal type was predominantly observed in six (86%) of seven AMT. An overall incidence of AMT in APBD patients was 32%. An undilated type of APBD is frequently associated with AMT and we believe, therefore, that clinicians should be aware of a possible coexistence of APBD and AMT.

Significance of laparoscopic excisional biopsy for polypoid lesions of the gallbladder.

Polypoid lesions of the gallbladder taken from 103 patients were examined to correlate clinical indicators with pathological characteristics. By ultrasonographic examination, no carcinoma was found in polypoid lesions with a diameter less than 1 cm. However, the incidence of carcinoma in those with diameters greater than 1 cm was 23%, a lower rate than expected from previous pathological studies. Comparison of ultrasonographic and actual measurements suggested that the size of cholesterol polyps tended to be overestimated by ultrasonography, suggesting that the apparent risk of cancer was decreased by cholesterol polyps. Laparoscopic cholecystectomy was performed in 30 patients with polyps. No complications were encountered, and operative time was significantly shorter (p < 0.01) than in the 116 laparoscopic cholecystectomies for cholelithiasis. This study demonstrated the difficulty in distinguishing large benign polyps from carcinoma by ultrasonography. To complete the diagnosis with less invasive intervention, we propose the use of laparoscopic cholecystectomy for patients with polypoid lesions larger than 1 cm by ultrasonographic estimation.