Vagina as a rare location of renal cell carcinoma metastasis.

INTRODUCTION: Metastatic renal cell carcinoma is often found in distant organs, including lung, bone, brain, and liver. Metastases to the vagina are extremely rare. CASE REPORT: The authors present a case of renal cell carcinoma metastasis to the anterior vaginal wall four months after nephrectomy in a 56-year-old patient. The vaginal lesions were excised. After two years the patient had no signs of recurrence or the disease progression. CONCLUSION: Vaginal metastases should be considered in differential diagnosis of female renal cell carcinoma patients presenting with vaginal bleeding of mass.

Early fetal heart ultrasonography as additional indicator for chromosomopathies.

OBJECTIVE: First trial of estimating values of scans of fetal heart structures (FHS) in first trimester of pregnancy, as more primary facts of possible chromosomopathies. MATERIALS AND METHODS: The study included 2,643 fetuses that were examined in first trimester of pregnancy on Sono CT convex (C5-2MHz), endovaginal (ev 8-4MHz), and linear transducers (L12-5MHz) during a period of eight years. Fetal heart was evaluated using appropriate software with broad-band transducers and color Doppler, Sono CT, and HD ZOOM technologies. The scan was performed by three experienced physicians. FHS were based on: left and right ventricle morphology; AV valves (atrioventricular) position and existence of primal ostium; relationship of left ventricle outflow tract (LVOT) and right ventricle outflow tract (RVOT) and great vessels on three vessel view (3VV) and estimation of ductal and aortic arch. RESULTS: Several developments, one being the ability to identify fetuses at risk for cardiac defects combining nuchal translucency (NT), ductus venosus (DV) Doppler, and evaluation of tricuspid regurgitation, have prompted reconsideration of the role of the first trimester prognostic factor of fetal evaluation. In low-risk pregnancies group, 36 (1.8%) fetuses were found to have congenital heart disease (CHD), and in high-risk pregnancies the number of fetuses with CHD was 75 (12%). Genetic amniocentesis or chorionic villus sampling (CVS) was performed in all fetuses with CHD. Forty-two (37.8%) fetuses with CHD were found to have chromosomal anomalies. Out of 111 fetuses with CHD 39 (35.1%) had an nuchal translucency (NT) above three mm. Out of 42 fetuses with chromosomal anomalies and CHD, 29 (69%) had an increased NT. CONCLUSION: Using first trimester fetal echosonography constitutes a further step in the earlier recognition of chromosomopathies, even in low risk groups. Still further steps are necessary as all facts of good clinical practice. In order to offer further benefits during pregnancies, improvements in diagnostics are still required.

Successful conservative treatment of a cervical ectopic pregnancy at 13 weeks.

BACKGROUND: Cervical ectopic pregnancy is a potentially life-threatening condition due to the unexpected occurrence of uncontrollable bleeding from the cervix. CASE REPORT: A 39-year-old secundigravida was admitted with amenorrhea of 12 weeks and four days due to suspected cervical pregnancy, without bleeding. The ultrasonography revealed a gestational sac at the anterior wall of the isthmic-cervical part with a single viable fetus, with crown-rump length (CRL) of 59 mm and regular heart rate. The serum ß-human chorionic gonadotropin (ß-hCG) level on admission was 143.416 mIU/l. Two possible therapeutic options were considered, (1) systemic methotrexate treatment and (2) uterine artery embolization with gelatine sponge. The first was rejected due to gestational age, viable fetus, high ß-hCG level, and CRL, and the later was rejected by the vascular surgeons due to lack of experience. The curettage was performed. After the evacuation, prostin was administered into cervix accompanied with tamponade. On the next day ß-hCG level was 44.342 mIU/l and the following day ultrasonography revealed the oval non-homogenous formation in the cervical cavity (blood clots or residual trophoblastic tissue); ß-hCG level was 36.501 mIU/l. The reintervention was performed on the fifth day after the curettage and 200 ml of coagulated blood was aspirated; ß-hCG level was 16.432 mlU/l. Since the isthmic-cervical part was slightly dilated (23 mm) seven days after the curettage, systemic methotrexate treatment (100 mg intramuscular) was initiated. Serum ß-hCG level on the second and fourth day after methotrexate were 12.553 mIU/l and 8.900 mIU/l, respectively. The second dose of 100 mg of methotrexate was administered intramuscular seven days after the first dose. Three days after, ß-hCG level was 2.329 U/l and ultrasound scan revealed normal isthmic-cervical finding. CONCLUSION: The present case report showed efficient fertility sparing conservative treatment, dilatation and curettage, of 13 week cervical pregnancy followed by systemic methotrexate.

Treatment of pregnant patient with disseminated intravascular coagulation (DIC) due to placental abruption--a case report.

A primigravid woman at 29th gestational week with placental abruption causing fetal death, that underwent instant cesarean section, developed a disseminated intravascular coagulation (DIC), revealed by hemoperitoneum and hematoma of the abdominal wall. After re-laparotomy and transfusion of blood, fresh plasma, and platelets, the patient was discharged from hospital on the 14th postoperative day completely recovered. To conclude, conservative surgical approach for DIC treatment is possible and safe. Novel antifibrinolitic drugs are recommended for obstetrical patients with DIC to enable a healthy subsequent pregnancy.

Pregnancy associated with melanoma and fetal anomalies: a case report and review of literature.

The estimated incidence of melanoma complicating pregnancy has ranged from 0.1 to 2.8 per 1,000 pregnancies. Here the Authors present a case of a 40-year-old pregnant woman, who was admitted to the Clinic of Obstetrics and Gynaecology in 26 weeks of gestation, with diagnosis of melanoma and suspected with fetal anomaly, as possible bowel obstruction, and polyhydraminos. The melanoma was asported with a wide local excision under local anesthesia. Histological evaluation revealed melanoma Stage Ib (Clark IV, Breslow thickness 1.2 mm, pT2a). Lymph node sonography of neck, axilla, inguinum, abdomen, and pelvis as well as chest radiography did not demonstrate any evidence of metastatic disease. After vaginal delivery at 37 weeks of gestation, the female preterm hypotrophic newborn was transferred to the Institute for Neonatology and underwent resection of duodenojejunal atresia with tapering duodenoplasty and duodenojejunal termino-terminal anastomoses due to intestinal obstruction. No evidence of the melanoma was found in the placenta. Two years later the child was healthy and the mother was disease-free.

Spindle-cell epithelioma of the vagina diagnosed during pregnancy--a case report.

Spindle-cell epithelioma or "mixed tumor" of the vagina is an unusual and intriguing vaginal tumor consisting of both epithelial and mesenchymal components. A case of spindle-cell epithelioma of the vagina diagnosed at delivery of a 31-year-old primiparous woman is described. The excision of the mass was performed immediately after the delivery, which was uneventful. The patient was regularly followed up and no evidence of local recurrence or dissemination was found 40 months after surgery. The presentation and the diagnosis of this kind of tumor in pregnancy, and its effect on the pregnancy and delivery are still largely unknown. Since it is unlikely that any institution will have a large number of patients with this rare disease, case reports add further information to this entity. As the number of cases studied is small, close follow-up is recommended although there has been no report in the literature of metastasis so far.

Primary melanoma of the vagina: a case report and review of literature.

Summary Primary melanoma of the vagina is a rare and very aggressive tumor with an incidence of only 0.46 per one million women per year and less than 250 cases reported in the literature. Here the authors present a case of a 60-year-old woman, gravida 5, para 5, post-menopausal by 28 years, admitted to the Clinic for Obstetrics and Gynecology, with recurrent vaginal bleeding for the last year and with the complaint of a palpable tumor near the vaginal introitus. The preoperative biopsy revealed melanoma. CT scan did not prove she had distant metastasis. The patient was treated surgically, with wide local excision of four x five cm measured lesion and safety margins of two cm. Bilateral inguinal lymphadenectomy was performed. Follow-up five months after initial diagnosis, revealed no evidence of local recurrency or distant metastasis.

Uterine tumor resembling ovarian sex cord tumor. Case report and review of literature.

A uterine tumor resembling an ovarian sex cord tumor (UTROSCT) shows a poly phenotypic immunophenotype with coexpression of epithelial, myoid, and sex cord markers, as well as hormone receptors. The authors present a case of a 59-year-old multiparous woman admitted to the Institute of Gynecology and Obstetrics Clinical Centre of Serbia in January 2010 due to prolonged vaginal bleeding and abdominal discomfort. The vaginal ultrasound showed an enlarged uterus size of 100 x 74 x 81 mm, with extended cavity with an unhomogenic content and myomas sized 54 x 69 mm located in fundus with secondary changes. She underwent abdominal hysterectomy with adnexectomy. Microscopic examination revealed submucosal uterine tumor with variabile histological organization that had anastomotic trabeculae with solid cellular grupations. Rare mitotic figures (2/10 HPF) were found. Additional imunohistochemistry showed immunophenotype: the sex cord areas were positive for vimentin(++), aSMA(++), AE1/AE3(+), PR(+), and ER(+). The poly phenotypic immunophenotype can be useful in differential diagnosis from other neoplasms but also suggests an origin of UTROSCT from uncommitted stem cell enabling for multidirectional differentiation.

Multiorgan thrombotic disorder in a young patient with primary antiphospholipid syndrome (APS) and ovarian tumor.

Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening condition with high mortality rate besides aggressive multimodal treatment. Underlying triggers of "thrombotic and cytokine storm" include pregnancy, inflammation, trauma, surgery, and infection. The authors present a case of a young female patient with primary antiphospholipid syndrome (APS) who was admitted to the hospital due to abdominal pain caused by ovarian tumor with elevated tumor markers. After the prophylactic anticoagulants and antibiotic treatment, surgery was performed. Suddenly after treatment, her clinical status deteriorated and she died regardless of intensive immunosupresive and anticoagulant therapy attempts. This condition requires all clinical awareness, timely diagnosis, and therapeutical approach, including a better understanding of the pathophysiology that leads to CAPS.

Perinatal outcome of singleton pregnancies following in vitro fertilization.

PURPOSE OF INVESTIGATION: To determine whether in vitro fertilization/intracytoplasmatic sperm injection (IVF/ICSI) singleton pregnancies are at increased risk for maternal and fetal complications than spontaneous singleton conceptions. MATERIALS AND METHODS: The pregnancy outcome of 634 singleton pregnancies after IVF/ICSI delivered at the Clinic for Gynecology and Obstetrics during the period January 2006 to January 2010 were compared to 634 matched singleton controls, matched one by one by age, parity, education, and body mass index (BMI). Differences in pregnancy outcomes between the groups were assessed using Student's t-test with Yates correction for continuous variables and Chi-squared test for categorical variables. RESULTS: The mean gestational age at delivery of the IVF group was 38.13 +/- 1.72 weeks, slightly shorter than spontaneously conceived singletons at 38.65 +/- 1.79 weeks. The diagnosis of gestational diabetes mellitus (GDM) was frequently made in the IVF group (11.82% vs 8.35%, t = 2.052, p < 0.05). Total preterm delivery rate of IVF pregnancies was 9.30%, significantly higher than the controls 5.85% (t = 2.33, p < 0.05), especially at the 30-32 weeks gestation period. The predominant mode of delivery after IVF pregnancy was cesarean section (80.75% vs 31.38% at spontaneously conceived, t = 17.71, p < 0.001), while vaginal route was the choice for naturally originated pregnancies 68.6% vs 19.24% (p < 0.01). No differences were found in the average birth weights, LBW, VLBW, SGA, and LGA regarding the pregnancy origin. Perinatal mortality rates were comparable among singletons with different pregnancy origin. CONCLUSIONS: Singletons from IVF/ICSI pregnancies have poorer perinatal outcome associated with higher rates of cesarean sections, preterm birth and prematurity, fetal malpresentation (breech presentation), and the occurrence of maternal GDM in pregnancy.

Malignant disease as a risk factor for surgical site infection.

INTRODUCTION AND OBJECTIVE: Postoperative infections are a great constituent of surgical complications. The most common one is surgical site infection (SSI), as well as vaginal and/or urinary tract infections, infections affecting distant organs and systems and systemic circulation leading to sepsis and septic shock. Our aim was to emphasize the effect of malignant disease on postoperative infection and to establish malignant disease as a risk factor for SSI, per se. MATERIAL AND METHOD: We designed a retrospective study in which 538 women who underwent surgery in the Gynecology and Obstetrics Clinical Center of Serbia during a six-month period in 2009 were analyzed. We collected relevant data regarding SSI incidence (CDC definitions), malignant disease (primary site, type and stage) and other potential risk factors for SSI. We used descriptive statistics, chi-square and Student's t test for comparison of variables with statistical significance atp < 0.05. We also used univariate, multivariate logistic regression and ROC analysis. RESULTS: Surgical site infection was present in 40 patients (7.5%). Univariate analysis revealed that the following factors were significantly related to SSI: age, malignant disease, stage of malignant disease, surgery longer than 120 min, postmenopause, diabetes mellitus, positive preoperative vaginal culture, ASA score and intraoperative blood loss. Multivariate analysis showed that the most important risk factors that contribute to SSI with RR of 4 and 5 are, respectively, FIGO II and FIGO III/IV stage of malignant disease (FIGO II p < 0.05 RR = 4.097; FIGO III/IV < 0.01 RR = 5.061). CONCLUSION: In our study malignant disease erupted as the most important risk factor for SSI. This brings us to question the pathophysiological mechanisms and systemic effects associated with malignant disease. There are few studies discussing the issue of malignancy as an isolated risk factor that 4-5 fold increases the risk of SSIs. It is of utmost interest to define protocols of antimicrobial prophylaxis for gynecological malignancy surgery as are suggested for some other malignancies.

Malignant fibrous histiocytoma of the ovary: a case report.

Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma of late adult life occurring predominantly in the extremities and the retroperitoneum. MFH of the ovary is very rare, with only six cases previously reported. A 67-year-old woman with a right pelvic tumor highly suspicious of ovarian carcinoma was submitted to exploratory laparotomy. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy, pelvic and paraaortic lymphadenectomy with right hemicolectomy along with permanent cutaneous ileostomy were performed. Since a storiform-pleomorphic type of MHF was diagnosed from histopathological and immunohistochemical findings, chemotherapy was proposed as the postoperative treatment. Despite extensive surgery with negative surgical margins, the patient had recurrence of the tumor within four months, and was submitted to secondary surgery. A combination of chemo- and radiotherapy was performed postoperatively, but the patient developed respiratory problems and died one year later from the primary diagnosis.

Postmenopausal palpable ovary and ovarian cancer.

INTRODUCTION: Ultrasound (US) examination is a much more reliable method for evaluation of potential ovarian cancer risk than gynecologic palpation. The aim of our study was to analyze the US characteristics of patients with palpable ovaries in light of potential for malignancy. PATIENTS AND METHODS: We analyzed 70 women ten years after menopause without increased CA 125 values. They underwent clinical and US exams (abdominal and transvaginal ultrasound), with special emphasis on US Doppler exam. RESULTS: Bimanuel gynecological examination showed palpable ovaries in 14 patients (palpable ovary group), and the remaining 56 patients were defined as the control group. US showed increased dimensions of palpable ovaries. Atypical follicular activity, deviation from verticalization, atypical ovaries and hyperechogenic punctations classified under germ cell cysts occurred statistically significantly more often in the palpable ovary group. Doppler flow showed pathological vascularization in five patients with palpable ovaries and the estrogen level was increased. After four to six months in these five patients we found a mild increase of estrogen levels and higher Doppler abnormality. Six months later, two patients had irregular bleeding and underwent surgical treatment. CONCLUSION: Every adnexal mass after menopausis demands special attention. Bimanuel gynecological exams should be used liberally. It is necessary to follow the dimensions of the ovary, describe the echostructure, as well as the edges of the ovary and other anatomical structures. Doppler flow measurement and estrogen levels are predictive and give more information. Controls should be in three to six month intervals in order to make a decision for surgical treatment.

Surgical treatment of ovarian cancer and early detection of venous thromboembolism.

INTRODUCTION: Deep vein thrombosis (DVT) is present in 10.6% patients after operative treatment for ovarian malignancy. We undertook the present study to find the risk factors for venous thromboembolism (VTE) after surgical treatment for ovarian cancer and to clarify the prognostic value of D-dimer and a positive PTP test (Wells score) in these patients. MATERIAL AND METHODS: A total of 31 consecutive patients with histologically confirmed ovarian cancer after surgery, clinically suspicious for DVT were followed from January 2006 to December 2008. All patients were operatively treated at the Clinical Center of Serbia. Study variables included age, cardiovascular disease, FIGO stage, histology, BMI, presence of massive ascites and tumor size, D-dimer level and Wells score. All patients were postoperatively administered anticoagulant therapy. RESULTS: DVT was found in nine of 31 patients (29.0%). High BMI and presence of massive ascites were significantly associated with DVT. D-dimer (DD) levels were high in 27 of out 31 patients (87.1%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 100, 18.2, 33.3 and 100%. Results of the PTP test (according to Wells score) was positive in 20 out of 31 patients (64.5%). PTP score was not significantly different in patients with or without VTE (p = 0.606). Sensitivity, specificity, PPV and NPV were 66.7, 36.4, 30.0 and 72.7%, respectively. CONCLUSION: Incidence of VTE after gynecological operations for ovarian cancer in our study was similar to other investigators. Obesity and the massive ascites are statistically significant risk factors. Measurement of DD level and ultrasonography could become the standard in predicting VTE in ovarian cancer surgery. The use of Wells score is not satisfying in these patients. Prediction of VTE after gynecological surgery needs further confirmation in randomized controlled trials.

Intestinal surgery in treatment of advanced ovarian cancer--review of our experience.

INTRODUCTION: In cases of advanced ovarian cancer bowel surgery is necessary during the primary surgical procedure, in the course of the disease for recurrence or palliation of the symptoms. Treatment with maximal cytoreductive surgery followed by chemotherapy in women with advanced ovarian cancer is well established. MATERIAL AND METHODS: We retrospectivly evaluated 56 women who were surgically treated for ovarian cancer over five years (from 2004 to 2008) at the Institute of Obstetrics and Gynecology, Clinical Center of Serbia. In 56 patients, 82 intestine operations were performed, which means that in some patients more than one intestine operation was performed. We analyzed patient characteristics, tumor features, intraoperative findings, pelvic node involvement, surgical procedure performed, indications for bowel surgery, and early postoperative complications. RESULTS: In our study the majority of patients had Stage III (82%) or IV (10%) carcinoma with poor differentiation. Epithelial ovarian cancer was the most common histopathological finding (78%) in our group of patients. There were 30 cases (53%) with serous, nine (16%) with mucinous and five (9%) with endometriod tumors. Bowel surgery was indicated in 12.2% of our patients with ovarian cancer which was mostly performed to reduce the volume of the tumor (68%), while it was indicated in recurrence of the disease in 18% of women. In addition to the standard surgery procedure, which includes removal of internal genital organs, omentum minus/majus, peritoneal tumor masses, large and small bowel resection were performed. Of 56 patients most underwent small bowel surgery--43 of a total of 82 intestinal operations (52.4%). Of these we performed small bowel resection in 34 (41.5% of all intestinal operations), while ileostomy and jejunostomy were performed in nine cases (11%). There were 39 colon operations (47.6%) and most of the cases underwent rectosygmoid resection with the Hartman procedure (33 or 40.2% of all intestinal operations). Other colon operations included hemicolectomy (3 cases--3.7%), transverse colon resection (2 cases--2.4%) and pancolectomy (1 case--1.2%). According to our experience, wound infection and febrile morbidity were the most common early postoperative complications. Mortality rates in the literature vary between 0% and 8%, and anastomotic complications between 0 and 4%, which is in agreement with our results. CONCLUSION: Radical surgical procedures in treatment of ovarian cancer including multi-organ resection are necesery to achieve a minimal residual disease state prior to initiating adjuvant chemotherapy. Bowel preparation and CT/MR imaging should be performed in patients with possible malignant ovarian masses.

Intestinal surgery and surgery of urinary tract in treatment of recurrent cervical cancer--case report.

A case of a 31-year-old patient admitted to the Institute with a diagnosis of recurrent cervical cancer after radical hysterectomy and radiation therapy 12 months before. The patient had intestinal and urinary obstruction and also the tumor compressed the iliac blood vessels superficially. She underwent clinical examination, pelvic and abdominal ultrasound and multislice CT scan. A recurring tumor with a diameter of 7 cm was diagnosed. It was localized in the left parailiac and obturator region and infiltrated the left ureter, left bladder side wall, sigmoid colon and iliac blood vessels superficially. The patient had left pelvic sidewall relapse, so she underwent a palliative surgical procedure. We evacuated the complete tumor together with the infiltrated parts of the left ureter, sigmoid colon and bladder. At the end of operation left ureterocystoneostomy was performed as well as the Hartmann procedure with anus praeter insertion. There were no significant postoperative complications. After the surgical treatment of the recurrence, we suggested that the patient continue treatment of her disease with chemotherapy.

Krukenberg tumor of gastric origin in pregnancy with dismal outcome.

Krukenberg tumors are mostly found as metastatic signet-ring cell adenomucinous carcinomas in young, premenopausal women. They are bilateral in 80% of the cases, and thus can be expected in pregnancy. A 31-year-old female was diagnosed by explorative laparotomy at 27 weeks of gestation with a Krukenberg tumor due to bilateral adnexal masses and a large amount of ascites. At surgery cesarean section with total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy and pelvic lymphadenectomy was performed. The neonate died 24 hours later due to prematurity and respiratory distress syndrome. The primary site of the cancer was detected metachronously two months after surgery and postoperative chemotherapy, as stomach adenomucinous carcinoma. In spite of surgery and postoperative multiagent chemotherapy, the patient died six months from the diagnosis of Krukenberg.

Vulvar neoplasm and reconstruction of a lesion with a vertical rectus abdominis myocutaneous flap: case report.

A 41-year-old nulliparous woman was admitted to the Institute of Gynecology and Obstetrics in 2007 with a painless tumor mass invading the whole vulvoperineal and gluteal region. Pathohistological biopsy revealed FIGO Stage II squamocellular invasive carcinoma, but clinically it was Stage IVa verucal vulvar carcinoma because of malignant infiltration to the distal part of the vagina and bilateral gluteal region. The patient underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy and partial vaginectomy. Reconstruction was performed after three weeks using a distally based vertical rectus abdominis myocutaneous flap (VRAM). A new entrance of the vagina was created. The patient was further treated with radiation therapy.

Radical abdominal trachelectomy in managing early cervical invasion.

The purpose of the study was to determine if radical abdominal trachelectomy with pelvic lymphadenectomy could be a method for treatment of early cervical cancer to preserve fertility. We examined 12 patients who were surgically treated from 2002 to 2006. The diagnostic method to determine cervical cancer was histologic examination by cone or biopsy. The histologic condition was well differented planocellular carcinoma. Two of the patients had Stage Ia1, seven had Ia2, and three had Ib1. We performed radical abdominal trachelectomy with pelvic lymphadenectomy. Resection edges were pathohistologically analyzed extemporaneously, as well as selective lymph nodes. According to the extempore analysis we determined if radical trachelectomy should be done. In one patient resection edges were positive, so she underwent radical hysterectomy. Postoperatively we found a positive lymph node in one patient, so radiation therapy was continued. In the two-year follow-up period we did not find any signs of residual cancer. We concluded that radical trachelectomy with pelvic lymphadenectomy could be an appropriate method for treatment of early-stage cervical cancer.

Renal cell carcinoma in pregnancy: a case report.

Renal cell carcinoma is seen most frequently after childbearing years, but occasionally is diagnosed in pregnancy. The pregnancy demands special considerations in terms of the diagnostic evaluation and management. A case of a patient with renal cell carcinoma diagnosed in the first trimester of pregnancy, which suddenly enlarged at the end of the second trimester, is presented. She underwent radical nephrectomy after delivery. Since the mother's welfare is the primary concern, surgical management should not be delayed.