Enhanced myometrial vascularity and AVM: A review on diagnosis and management.

Uterine Arteriovenous malformations (AVM) are vascular disorders characterized by complex high-flow tangles of abnormal vessels connecting arteries and veins with bypassing capillaries. Recently, the terminology applied to describe uterine AVMs has been modified. Most AVMs are acquired. The term enhanced myometrial vascularity (EMV) is used to describe any condition in which any uterine pathology may lead to increased myometrial vascularity regardless of the absence or presence of residual tissue of gestation.

COVID-19, An early investigation from exposure to treatment outcomes in Tehran, Iran.

BACKGROUND: There is a growing need for information regarding the recent coronavirus disease of 2019 (COVID-19). We present a comprehensive report of COVID-19 patients in Iran. MATERIALS AND METHODS: One hundred hospitalized patients with COVID-19 were studied. Data on potential source of exposure, demographic, clinical, and paraclinical features, therapy outcome, and postdischarge follow-up were analyzed. RESULTS: The median age of the patients was 58 years, and the majority of the patients (72.7%) were above 50 years of age. Fever was present in 45.2% of the patients on admission. The most common clinical symptoms were shortness of breath (74%) and cough (68%). Most patients had elevated C-reactive protein (92.3%), elevated erythrocyte sedimentation rate (82.9%), and lymphocytopenia (74.2%) on admission. Lower lobes of the lung were most commonly involved, and ground-glass opacity (81.8%) was the most frequent finding in computed tomography scans. The administration of hydroxychloroquine improved the clinical outcome of the patients. Lopinavir/ritonavir was efficacious at younger ages. Of the 70 discharged patients, 40% had symptom aggravation, 8.6% were readmitted to the hospital, and three patients (4.3%) died. CONCLUSION: This report demonstrates a heterogeneous nature of clinical manifestations in patients affected with COVID19. The most common presenting symptoms are nonspecific, so attention should be made on broader testing, especially in age groups with the greatest risk and younger individuals who can serve as carriers of the disease. Hydroxychloroquine and lopinavir/ritonavir (in younger age group) can be potential treatment options. Finally, patients discharged from the hospital should be followed up because of potential symptom aggravation.

Modified MR scoring system for assessment of sonographically indeterminate ovarian and adnexal masses in the absence of dynamic contrast-enhanced.

OBJECTIVES: Dynamic contrast-enhanced (DCE) MRI is not available in all imaging centres to investigate adnexal masses. We proposed modified magnetic resonance (MR) scoring system based on an assessment of the enhancement of the solid tissue on early phase postcontrast series and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) map and investigated the validity of this protocols in the current study. MATERIALS AND METHODS: In this cross-sectional retrospective study, pelvic MRI of a total of 245 patients with 340 adnexal masses were studied based on the proposed modified scoring system and ADNEX MR scoring system. RESULTS: Modified scoring system with the sensitivity of 87.3% and specificity of 94.6% has an accuracy of 92.1%. Sensitivity, specificity, and accuracy of ADNEX MR scoring system is 96.6%, 91%, and 92.9%, respectively. The area under the receiver operating characteristic curve for the modified scoring system and ADNEX MR scoring system is 0.909 (with 0.870-0.938 95% confidence interval [CI]) and 0.938 (with 0.907-0.961 95% CI), respectively. Pairwise comparison of these area under the curves showed no significant difference (P = .053). CONCLUSIONS: Modified scoring system is less sensitive than the ADNEX MR scoring system and more specific but the accuracy is not significantly different. ADVANCES IN KNOWLEDGE: According to our study, MR scoring system based on subjective assessment of the enhancement of the solid tissue on early phase postcontrast series and DWI with ADC map could be applicable in imaging centres that DCE is not available.

Endocervical adenocarcinoma implantation in episiotomy scar: a case report and review of the literature.

BACKGROUND: Cervical cancer is a rare malignancy in the 1st months of pregnancy. Implantation of this cancer in an episiotomy scar is a condition that is rarely reported. CASE PRESENTATION: We reviewed the literature on this condition and reported a 38 year-old Persian patient who had been diagnosed with cervical cancer, clinically stage IB1, 5 months after a term vaginal delivery. She underwent transabdominal radical hysterectomy with ovarian preservation. Two months later she presented with a mass-like lesion in the episiotomy scar which was proved to be of cervical adenocarcinoma origin after biopsy. The patient was scheduled for chemotherapy with interstitial brachytherapy, an alternative to wide local resection, with successful long-term disease-free survival. CONCLUSION: Implantation of adenocarcinoma in an episiotomy scar is a rare occurrence in patients with a history of cervical cancer and previous vaginal delivery near the time of diagnosis which requires extensive local excision as a primary treatment when feasible. The proximity of the lesion to the anus can lead to major complications of extensive surgery. Alternative chemoradiation combined with interstitial brachytherapy can be successful in eliminating cancer recurrence without compromising the functional outcome.

Predictive value of B-human chorionic gonadotropin for progression of molar pregnancy to persistent gestational trophoblastic neoplasm.

BACKGROUND: This study aimed to assess the predictive value of B-human chorionic gonadotropin (B-hCG) for progression of molar pregnancy to persistent gestational trophoblastic neoplasm (GTN). METHODS: This cohort study evaluated 126 patients with molar pregnancy. The patients were selected among those presenting to Yas Hospital in 2016-2017. All female patients with molar pregnancy hospitalized in this hospital who underwent evacuation were enrolled. After evacuation, the patients underwent ultrasound examination to measure their endometrial thickness. Also, presence of complete or partial mole was pathologically assessed. The B-hCG titers were measured before and at 48 h, 1 week, 2 weeks, and 3 weeks after the evacuation. The follow-up was continued until the B-hCG titer was negative or the patient was classified as a case of GTN according to the FIGO classification. Data were analyzed by the independent t-test, Mann-Whitney Test, χ2 test, receiver operating characteristic (ROC) curve, and linear regression. RESULTS: Of 126 patients with molar pregnancy, 13 developed GTN. The mean ratio of pre-evacuation B-hCG titer to the value at 3 weeks after evacuation was 0.02±0.005 in the full recovery and 0.06±0.04 in the GTN group, indicating an area under the curve (AUC) of 0.904. CONCLUSIONS: The ratio of pre-evacuation B-hCG titer to the value at 3 weeks after the evacuation of mole can serve as an excellent predictor for development of GTN.

The impact of lymphovascular space invasion on survival in early stage low-grade endometrioid endometrial cancer.

BACKGROUND: The lymphovascular space invasion (LVSI) is suggested as a prognostic factor for endometrial cancer in many studies, but it has not yet been employed in FIGO staging system. The present study was aimed to evaluate the impact of LVSI on survival in patients with early stage endometrioid endometrial cancer. METHODS: This retrospective cohort was conducted on early stage endometrial cancer patients who underwent surgical staging [total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO)] and omental biopsy at Referral Teaching Hospitals of Tehran from 2005 to 2021. Patient's age, menopause status, tumor grade, tumor size, depth of myometrial invasion, LVSI and lower segment involvement were recorded. Data were analyzed with SPSS 22. RESULTS: 415 patients with stage I and grade 1-2, endometrioid endometrial cancer were analyzed. 100 patients (24.1%) were LVSI-positive. 3-year and 5-year survival rates were 97.1% and 88.9%, respectively. Recurrence occurred in 53 patients (12.8%). 3-year overall survival rates in LVSI-negative and LVSI-positive were 98.7% and 92%. These rates for 5-year survival were 92.1% and 79%, respectively. Recurrence rates in LVSI-negative were 8.9% while it was 25% in LVSI-positive cases. Multivariate analysis showed that LVSI has significant correlation with 3-year and 5-year overall survival rates. CONCLUSIONS: LVSI in early stage endometrial cancer significantly and independently influences 3-year and 5-year survival rates and acts as a strong prognostic factor in these patients. LVSI should be implemented in endometrial cancer staging systems due to its significant correlation with cancer recurrence rates and 5-year survival rates.

Cervical intraepithelial neoplasia in non-16/18 high-risk human papilloma virus positive/cytology negative women: An alternative approach in poor resource areas.

OBJECTIVE: Because the specific prevalence and carcinogenesis of non-16/18 high-risk (hr) Human Papillomavirus (HPV) is not fully understood, we designed a study with aim of evaluating the risk of high-grade cervical intraepithelial neoplasia (CIN) in non-16/18 hr-HPV positive/cytology negative cases and assessing the distribution of non-16/18 hr-HPV subtypes. MATERIALS AND METHODS: This cross-sectional study was conducted on 138 non-16/18 hr-HPV positive/cytology negative women, who were referred to the gynecologic oncology clinic of Yas hospital, affiliated with Tehran University of Medical Sciences, January 2021 to 2022. RESULTS: Among the detected types, HPV 31 was the most frequent type. 63 cases underwent biopsy as indicated based on colposcopic examination with acetic acid 3% application among which 34 had normal results. In the remaining 29 cases, 25 had insignificant findings. CIN2 was reported in 2 cases, one with HPV 31, 45, 58, and the other with HPV 58. CIN3 was also detected in 2 cases, one with HPV 31 and the other with HPV 35, 45. The overall incidence of high-grade CIN was 2.8%. A statistically significant (P-value = 0.046) difference was detected between patients with high-grade CIN compared with the others regarding the Hookah usage. CONCLUSION: The risk of CIN among non-16/18 hr-HPV positive/cytology negative cases is noticeably low. Based on ASCCP guidelines return testing at 1 year without immediate colposcopy seems sufficient; however, because of many reasons doing immediate colposcopy rather than 1-year follow-up may be a more accessible approach in resource poor, low-income countries such as ours.

Pregnancy outcome in patients with stage 1a endometrial adenocarcinoma, who conservatively treated with megestrol acetate.

OBJECTIVE: The most effective treatment of well-differentiated endometrial carcinoma is surgery. The aim of this study is the evaluation of megestrol acetate on young patients with well-differentiated endometrial cancer who wish to preserve their fertility, with regard to the receptors. METHODS: 16 patients were treated initially with 160 mg/d of megestrol acetate and continued with 320 mg/d for non-responsive cases. All patients followed with FD&C and hysteroscopy. The responsive patients were referred to IVF group. RESULTS: Response rate to hormonal therapy was 10/16 (62.5%). The mean time of responding was 7.5 months. Other six (37.5%) patients underwent total abdominal hysterectomy (TAH). Of 10 patients who responded to hormonal therapy, one exited of the study because of her husband's infertility. Two patients are under IVF. Three patients did not get pregnant and four patients became pregnant and finally underwent TAH. All patients had progesterone receptors. Only one patient lacked estrogen receptors; who also responded to treatment. CONCLUSION: Progestins treatment of these patients who want to have child may be useful, but close long-term follow-up is necessary. The evaluation of estrogen and progesterone receptors assay may be useful in predicting response to the treatment.

Factors related to clinical breast examination: A cross-sectional study.

Background and Aim: Breast cancer is one of the most common types of cancer among women as well as one of the most serious and important public health issues in developing countries. The aim of the present study was to evaluate the factors related to clinical breast examination in women in Tehran. Method: This cross-sectional study was conducted on 859 women in Tehran, Iran in 2020. Logistic regression was applied to identify determinant factors that related to clinical breast examination. Result: The prevalence of clinical breast examination was 52.6%. Results indicated significant differences between those who underwent clinical breast examination and those who had a nonclinical breast examination in terms of age, housing conditions, marital status, problem in the breast, perceived susceptibility, perceived barriers, fatalism, and self-care. Conclusion: It is essential to inform and educate women about breast cancer and associated complications and problems after being diagnosed with breast cancer as well as about the screening and diagnostic methods, including the need for clinical breast examination by a specialist.

Importance of pre-operative COVID-19 screening test in elective surgeries.

Background and Objectives: Since the COVID-19 pandemic initiation, more than 28 million elective surgeries were postponed with a cancellation rate of 72.3%. However, studies suggested that the patient treatment should be conducted within 12 weeks of diagnosis because delay in treatment might have had adverse impacts on patients' health status, prognosis, and pathologic stage. Hence, the current study aimed to assess the importance of a pre-operative COVID-19 screening test for the patients were candidates for elective surgery. Materials and Methods: This cross-sectional study was conducted on 141 patients who were candidates for any type of elective surgeries or cesarean section at a tertiary university-based hospital, between June 2020, and September 2020. Results: The mean age of participants was 41.38 ± 11.66 years. Of them, 91.5% were women and 8.5% were men. The COVID-19 polymerase chain reaction (PCR) screening tests were positive in 12 (8.5%) patients. From whose PCR tests were positive, only five people (less than half) had symptoms of COVID-19 such as fever (three patients), a distinctive smell (two patients), and cough (one patient). Suspected exposure to COVID-19 was reported in four of them. Conclusion: In this study, we found that more than half of PCR positive COVID-19 patients were asymptomatic. Therefore, to have a safe hospital environment, and improve patient health outcomes, the COVID-19 screening test should be applied before any interventions.

The importance of correct radiological diagnosis in (adenoma malignum): a case report.

Minimal deviation adenocarcinoma (MDA) of the cervix otherwise known as adenoma malignum is a rare variation of cervical adenocarcinoma. Radiological evaluation plays a great role to ensure an early diagnosis. Here, we report a 48-year-old woman who was presented with a mucoid vaginal discharge 10 years after a supracervical hysterectomy. Despite normal biopsy and cytology, magnetic resonance imaging showed a large cervix and multiple cervical cysts that considered adenoma malignum as a differential diagnosis. She underwent surgery and the pathology confirmed the adenoma malignum. In conclusion, radiologists, as well as gynecologists, and also pathologists may consider MDA among the differential diagnosis in patients with a vaginal discharge and multicysts in the cervix even after hysterectomy despite normal cytology and biopsy.

Sexual Quality of Life in Gynecological Cancer Survivors in Iran.

OBJECTIVE: Patients with gynecological cancer might suffer from suboptimal sexual quality of life. This cross sectional study aimed to assess the sexual quality of life in the survivors of gynecological cancers and was recruited in a teaching hospital affiliated to Tehran University of Medical Sciences between 2018 and 2020. MATERIAL AND METHODS: The data was collected by a web-based platform with validated self-administered questionnaires including demographic information, and the Sexual Quality of Life-Female (SQOL-F) questionnaire. The data were analyzed using appropriate tests. RESULTS: Totally, 42% (106) of the participants had a sexual relationship in the last 6 months. The mean (SD) of sexual quality of life score was 46.84 (11.86) with the range of 0-90. The patients with cervical cancer had a worse sexual quality of life in Psychosexual Feelings (P=0.048) and Self-Worthlessness (p=0.036) compared with other gynecological cancers. Sexual quality of life did not improve or worsen over time. CONCLUSION: It is concluded poor sexual quality of life need further attention in the traditional societies and healthcare providers are urged to improve their sexual quality of life.
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Quality of Life in Patients with Gynecological Cancers: A Web-Based Study.

INTRODUCTION: Gynecological cancers are common in adult women. One of the most important goals in the management of these patients is to improve quality of life, along with survival as a traditional outcome. The aim of this study was to evaluate quality of life in gynecological cancers in Iran. METHODS: This cross-sectional study was performed on a sample of patients with gynecological cancers including uterine, ovarian, cervical, and vulvovaginal attending a teaching hospital affiliated to Tehran University of Medical Sciences between 2014 and 2019. The data was collected by a web-based platform with validated self-administered questionnaires including demographic information, the EORTC QLQ-C30 and the Hospital Anxiety and Depression (HADS). The data were analyzed using appropriate tests. RESULTS: In all 251 patients were studied. The mean age of patients was 52.8±12.4 years and 43% had uterine, 30% had ovarian, 25% had cervical, and 2% had vulvovaginal cancer. The mean global quality of life score as measured by the EORTC QLQ-C30 was 59.8 ± 24.9. Women with ovarian cancer had the highest and women with cervical cancer had the lowest global quality of life score. There were significant differences in emotional, cognitive and global quality of life by cancer diagnosis (p <0.05). Although not significant, overall physical, role, cognitive and social functioning was found to be better in women who had been treated with surgery. The mean anxiety and depression score were 8.7± 5.0 and 7.1 ± 5.2, respectively. CONCLUSION: The results demonstrated that patients with gynecological cancers had a low quality of life, and experience higher anxiety and depression.
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Differentiation of Benign from Malignant Adnexal Masses by Dynamic Contrast-Enhanced MRI (DCE-MRI): Quantitative and Semi-quantitative analysis at 3-Tesla MRI

Background: To evaluate the utility of the pharmacokinetic modeling derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in differentiating benign from malignant adnexal masses. Methods: A total of 43 patients with 49 complex adnexal masses (27 benign, 3 borderline, and 19 malignant lesions) underwent preoperative DCE-MRI examinations on a 3 Tesla MRI. Using extended Tofts' model, quantitative analysis was performed in the solid components of all tumors. Three pharmacokinetic parameters were defined as volume transfer coefficient (Ktrans), the rate constant (Kep), and the plasma volume (Vp). Semi-quantitative analysis was also performed and the values of relative signal intensity (SI rel) wash-in-rate (WIR), the initial area under the curve (iAUC60), time-to-peak (TTP) and wash-out-rate (WOR) were calculated. Receiver operating characteristic (ROC) curve analysis was performed to evaluate diagnostic characteristics of each DCE-MRI parameter in differentiating borderline/malignant tumors from benign lesions and to provide the optimal cutoff values for these variables. Results: SI rel had the highest diagnostic value (AUC=0.872; p<0.001; cut-off=121.4 associated with an overall accuracy=79.6%, sensitivity=95.5%, specificity=66.7%, NPV=94.8% and PPV=70.0%). Ktrans had the second highest AUC=0.836 (p<0.001; cut-off=0.034 associated with an overall accuracy=79.6%, sensitivity=86.4%, specificity=74.1%, NPV=87.0% and PPV=73.1%). The other factors found to be acceptable diagnostic parameters for borderline/malignant lesions included WIR (AUC=0.816; p<0.001), iAUC60 (AUC=0.808; p<0.001), Vp (AUC=0.795; p<0.001), SI max (AUC=0.737, p=0.005), SI peak (AUC=0.737; p=0.005) and Kep (AUC=0.681; p=0.031). Conclusion: Quantitative DCE-MRI is a relevant tool for differentiating benign from malignant adnexal masses. Among all the DCE parameters, SI rel and Ktrans are the most accurate discriminators.

The Impact of Lymphovascular Space Invasion on Recurrence and Survival in Iranian Patients With Early Stage Endometrial Cancer.

BACKGROUND: The aim of this study was to assess the impact of lymphovascular space involvement (LVSI) on recurrence and survival in early stage of endometrial cancer (EC). METHODS: Patients with EC referred to Imam Khomeini Hospital in Tehran were examined and enrolled over a 10-year period (2004 - 2015). The effect of LVSI on recurrence and overall survival was analyzed using the Kaplan-Meier and log-rank test methods. RESULTS: A total of 160 patients with early stage EC were identified. Out of 160 women with EC, 135 (84.4%) underwent primary surgery. One hundred and twenty-one (76.2%) patients were not found to have LVSI, whereas 38 (23.8%) were found to have LVSI. Of the 38 patients with LVSI, 21 (55.3%) had endometrioid cell type tumor, 10 (26.3%) had serous, one (2.6%) had clear cell and six (15.8%) had adeno-squamous cell type tumor. CONCLUSION: The presence of LVSI represents a factor strongly associated with high risk of recurrence and poor survival in early stage EC. Patients with lower International Federation of Obstetrics and Gynecology (FIGO) stages may be at increased risk of recurrence and a poor overall survival if the pathological findings confirm the presence of LVSI. Thus, LVSI should be added to the traditional factors used to decide whether patients with early stage EC are at high risk of recurrence and adjuvant therapy planning.

Molar pregnancy presents as tubal ectopic pregnancy.

Hydatidiform moles are abnormal gestations characterized by the presence of hydropic changes affecting some or all of the placental villi. Hydatidiform moles arise as a result of the fertilization of an abnormal ovum. In this report, the patient was a 29 year old Asian woman who had induction of ovulation with letrozol. Since the majority of molar gestations arise within the uterine cavity thus the occurrence of a hydatidiform mole within ectopic gestational tissue is rare. It is important to differentiate a hydatidiform mole from a conventional ectopic pregnancy, particularly in infertile women who have a history of ovulation induction.