Is magnetic resonance imaging useful in early evaluation of women on neoadjuvant chemotherapy for locally advanced cervical cancer?

OBJECTIVE: To evaluate the accuracy of magnetic resonance imaging (MRI) in staging cervical tumors after neoadjuvant chemotherapy (NACT). METHODS: 26 women, affected by locally advanced cervical cancer and triaged for surgery after NACT, were submitted to three cycles of neoadjuvant chemotherapy. All patients were submitted to MRI before and after NACT. We evaluated the MRI sensitivity and specificity in staging cervical tumors after chemotherapy, relating MRI findings after NACT with the pathological findings as the gold standard. RESULTS: In our series, MRI sensitivity was 58.8% and specificity was 66.7%. CONCLUSIONS: In our study MRI accuracy after NACT was lower than that of MRI used to stage patients with early cervical cancer scheduled for primary surgery, reported by the literature. MRI false negative cases are the major problem because of the delay in application of an effective therapy in non responders to NACT.

Multidetector computerized tomography enteroclysis vs. rectal water contrast transvaginal ultrasonography in determining the presence and extent of bowel endometriosis.

OBJECTIVES: To compare the accuracy of multidetector computerized tomography enteroclysis (MDCT-e) and rectal water contrast transvaginal ultrasonography (RWC-TVS) in determining the presence and extent of bowel endometriosis. METHODS: This prospective study included 96 patients of reproductive age with suspicion of bowel endometriosis. Patients underwent MDCT-e and RWC-TVS before operative laparoscopy. Findings of MDCT-e and RWC-TVS were compared with histological results. The severity of pain experienced during MDCT-e and RWC-TVS was measured by a 10-cm visual analog scale. RESULTS: Fifty-one patients had bowel endometriotic nodules at surgery. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the diagnosis of rectosigmoid endometriosis were 95.8% (46/48), 100.0% (48/48), 100.0% (46/46), 96.0% (48/50) and 97.9% (94/96) for MDCT-e and 93.8% (45/48), 97.9% (47/48), 97.8% (45/46), 94.0% (47/50) and 95.8% (92/96) for RWC-TVS. MDCT-e was associated with more intense pain than was RWC-TVS. CONCLUSIONS: MDCT-e and RWC-TVS have similar accuracy in the diagnosis of rectosigmoid endometriosis, but patients tolerate RWC-TVS better than they do MDCT-e.

Transvaginal ultrasonography with water-contrast in the rectum in the diagnosis of bowel endometriosis.

AIM: The rectosigmoid is the most frequent location of intestinal endometriosis. Although several techniques have been proposed for the diagnosis of intestinal endometriosis, no gold standard is currently available. In this review, we describe in details a new technique for the diagnosis of rectosigmoid endometriosis: rectal water-contrast transvaginal ultrasonography. METHODS: During transvaginal ultrasonography, an assistant inserts a 6-mm flexible catheter through the anal os into the rectal lumen; the insertion of this catheter is evaluated under ultrasonographic control. Water contrast is instilled slowly in the rectum to permit intestinal distension. The colonic wall evaluation is obtained by positioning the transvaginal probe against a length of the sigmoid colon to obtain either axial or longitudinal images. The injection of the saline solution facilitates the identification of recto-sigmoid endometriotic nodules which appear as rounded or triangular hypoechoic masses, located anterior or lateral to the bowel. RESULTS: This technique has high sensitivity and specificity in the diagnosis of rectal infiltration in women with rectovaginal endometriosis. The distance between the nodules and the mucosal layer permits to estimate the depth of infiltration of these endometriotic lesions within the intestinal wall. Rectal distensibility can be estimated. The procedure is well tolerated by the patients. CONCLUSION: Water distension of the rectum facilitates the identification of intestinal endometriosis during transvaginal ultrasonography.

Does transvaginal ultrasonography combined with water-contrast in the rectum aid in the diagnosis of rectovaginal endometriosis infiltrating the bowel?

BACKGROUND: The aim of this study was to determine whether adding water-contrast in the rectum during transvaginal ultrasonography (RWC-TVS) improves the diagnosis of rectal infiltration in women with rectovaginal endometriosis. METHODS: This prospective study included 90 women, with suspect rectovaginal endometriosis, who underwent operative laparoscopy. TVS and RWC-TVS were independently performed by different investigators. RWC-TVS was performed by injecting saline solution into the rectal lumen under ultrasonographic control through a 6-mm catheter. Presence of rectovaginal nodules, presence and degree of rectal infiltration, and the largest diameter of the bowel nodules were evaluated. Ultrasonographic results were compared to surgical and histological findings. RESULTS: Although RWC-TVS had higher accuracy than TVS in diagnosing rectovaginal endometriosis, the difference between the two techniques was not statistically significant. RWC-TVS was significantly more accurate than TVS in determining the presence of endometriotic infiltration reaching at least the muscular layer of the rectal wall. The sensitivity of RWC-TVS in identifying rectal lesions was 97%, the specificity 100%, the positive predictive value 100% and the negative predictive value 91.3%. RWC-TVS caused a higher intensity of pain than TVS. CONCLUSIONS: RWC-TVS determines the presence of rectovaginal nodules infiltrating the rectal muscularis propria more accurately than TVS; RWC-TVS could be used when TVS cannot exclude the presence of rectal infiltration.

Massive ovarian edema: a case of over 30 cm ovarian mass in young woman.

Massive ovarian edema is a rare entity that can be confused with ovarian neoplasm. A 20-year-old nulligravid woman presented with a large solid pelvic mass and abdominal mass. On examination a solid mass was found which extended from the pelvis until over the umbilical transversal line. Abdominal ultrasound revealed a solid non-homogenous mass originating from the right ovary with largest diameter of over 30 cm, fine internal echoes, regular margins, and poor vascularization. The abdominal computed tomography (CT) image was non-contributory. Blood work including hematology and biochemistry was normal. There was no sign of systemic infection and the tumour markers are negative. Unilateral adnexectomy was performed during exploratory laparotomy. Histological examination demonstrated massive ovarian edema. The adnexa weighted 1,585 g. Massive edema of the ovary remains difficult to diagnose before surgery because it may clinically and radiologically mimic an ovarian neoplasm. The majority of cases present with recurrent abdominal pain or a palpable adnexal mass. Nausea with or without vomiting can be present. Menstrual irregularities are common. Some patients have signs of masculinization including hirsutism, clitoromegaly, voice deepening, precocious puberty. However, this entity should be considered in young women presenting with an ovarian mass and abdominal pain. Treatment of massive ovarian edema is controversial.

Breast cancer metastatic to the vulva after local recurrence occurring on a rectus abdominis myocutaneous flap: a case report and review of the literature.

INTRODUCTION: Vulvar metastases are the third largest group of malignant tumors of the vulva. We report the tenth case of breast cancer vulvar metastases arising 11 years after the primary diagnosis of breast ductal carcinoma and the first occurring eight years after a local recurrence on a rectus abdominis myocutaneous flap. CASE REPORT: A 49-year-old woman presented with a voluminous lump of the left labium majus and enlargement of the ipsilateral inguinal lymph nodes. The mass was removed together with the ipsilateral inguinal lymph nodes. Microscopic evaluation of the removed lump revealed massive carcinomatous infiltration. No in situ lesions nor normal breast tissue were identified. CONCLUSIONS: Unusual breast cancer metastases sites should not be ruled out. Our case differs from the preceding cases because this patient underwent plastic surgery with reconstruction of the breast with a rectus abdominis myocutaneous flap one year after mastectomy and developed a local recurrence three years thereafter. It can be hypothesized that lymphatic spread through newly formed lymphatics occurred.

Pemetrexed disodium in ovarian cancer treatment.

INTRODUCTION: Current therapies for recurrent ovarian cancer (OC) yield relatively modest improvements in survival. Many drugs are available but recently a renewed interest is addressed on antimetabolite drugs. Pemetrexed (PEM) is a multitargeted antifolate cytotoxic agent mainly used in lung cancer. AREAS COVERED: This review summarizes the available evidence on the use of PEM in the treatment of OC. This article consists of material obtained via Medline, PubMed and EMBASE literature searches, up to November 2011. Currently available published data on mechanism of action, pharmacokinetics, safety and efficacy of PEM in the treatment of recurrent OC are described. EXPERT OPINION: Eight trials evaluated the use of PEM in OC patients. Studies using PEM in combination with carboplatin in platinum-sensitive OC suggested that the response rate is similar to other combination therapies. However, based on the absence of randomized trials comparing this doublet with currently used combination treatments, it is difficult to draw conclusions on the efficacy of PEM regimens in these patients. In platinum-resistant OC patients, two studies suggested that PEM alone might have equivalent activity to other single-agent treatment. Further pharmacogenomic and clinical data are warranted to better define the role of PEM in the treatment of recurrent OC.

Immunohistochemical localization of epidermal growth factor receptor in leiomyomas from women treated with goserelin depot.

Epidermal growth factor receptors (EGFr) were studied by immunohistochemistry in human myometrium and leiomyomas from women treated with the GnRH agonist (GnRH-a) goserelin. The results were compared with those obtained from women not treated. Vessel cells of leiomyomas and myometrium were always more immunoreactive than fibrocytes and myocites. In fibroids from treated patients the histochemical score (HSCORE) of vessel cells was always significantly lower (p less than 0.001) than in control patients. Our data confirm a role of EGF also in fibroid growth and suggest that, the blood supply reduction associated with the volume reduction of these tumours, consequent to the GnRH-a treatment, could be EGF mediated.