Accuracy of intra-operative frozen section analysis of ovarian tumours.

During operative treatment for ovarian tumours assistance is frequently required to make decisions regarding malignancy status and the extent of the ensuing procedure. Intra-operative frozen section analysis may be useful, provided there is adequate acquaintance with the correlation between using frozen sections and permanent histopathological sections for diagnosis at the institution where the operation is being undertaken. This retrospective study aimed to determine this correlation. Findings from 131 intra-operative frozen sections were compared with the subsequent diagnosis from permanent histopathological sections for women with benign, borderline and malignant ovarian tumours at the Maribor Teaching Hospital (now the University Clinical Centre Maribor) between 1 January 1993 and 31 December 2001. Frozen-section findings corresponded to histopathological findings in 84.7% of cases, with 15.3% false-negative and no false-positive results. For benign, borderline and malignant ovarian tumours, sensitivity was 100.0%, 76.1% and 89.0%, respectively, and specificity was 90.6%, 90.6% and 100.0%, respectively. The majority of errors occurred in diagnosing mucinous borderline tumours. Precise pre-operative diagnosis is extremely important in the treatment of ovarian tumours.

The role of procalcitonin in gynaecological surgery.

We evaluated postoperative concentrations of inflammatory indicators, including procalcitonin, after gynaecological operations for benign and malignant tumours in patients with a normal postoperative course and assessed the utility of procalcitonin in differentiating between non-bacterial inflammation and bacteraemic complications in the postoperative period. This prospective study included 99 patients: 47 after a standard gynaecological operation (Piver I) and no postoperative infectious complications (group 1), 35 after a major procedure (Piver II or III) and no postoperative infectious complications (group 2), and five with postoperative sepsis after Piver II or III procedures (group 3). We also studied serum procalcitonin concentrations in a group of 12 patients (group 4) with terminal forms of gynaecological cancer who were hospitalized for palliative treatment but did not undergo surgery. Postoperative C-reactive protein (CRP) concentration corresponded with extent of tissue trauma in groups 1 and 2 and was significantly lower in group 1 than group 2. Inflammatory indicators were highest in groups 1 and 2 on postoperative day 2. In group 3, in which sepsis developed, values were highest on postoperative day 4. In particular, procalcitonin was > 2 ng/ml in all patients with postoperative sepsis by postoperative day 2 but was always 2 ng/ml, with no signs of infection or raised CRP. It is concluded that, for early detection of postoperative infectious complications after gynaecological surgery, procalcitonin levels > 2 ng/ml are more specific than CRP.

Quality of life and the effect on social status among Slovenian women after breast cancer treatment.

This study investigated whether the type of surgical procedure used to treat breast cancer (mastectomy versus breast-conserving lumpectomy) had any effect on the quality of life and social status of women. The prospective analysis included 382 women newly diagnosed with non-metastatic breast cancer who had undergone a surgical intervention for breast carcinoma at our institution: 198 patients had undergone mastectomy with axillary lymphadenectomy and 184 patients had undergone breast-conserving lumpectomy with local axillary lympha-denectomy. The post-mastectomy women reported significantly more financial problems, a lowered social status and more physical symptoms compared with the breast-conserving post-lumpectomy patients. The patients that underwent lumpectomy were more satisfied with their body image and their sexual life. Since the adverse financial effects of wage loss can significantly decrease a patient's quality of life, this study indicates that post-mastectomy patients in particular need to be protected more effectively against a decline in their social status.

Primary breast cancer of the vulva: a case report and review of the literature.

Since 1872, 40 cases of ectopic mammary gland tissue in the vulva have been reported in the literature. Out of these, 12 had a primary cancer in the ectopic breast tissue. Seven metastases of an orthotopic breast cancer have been found in this location. We are presenting the 20th case of cancerous breast tissue in the vulva whom we classified as the 13th case of primary cancer based on clinical and histopathological criteria of primary and metastatic malignant disease. Because of the advanced age of the patient, wide local excision followed by adjuvant hormonal therapy was opted for. Nineteen months after surgery, there is no evidence of recurrent disease. Due to the rarity of this entity, its management presents therapeutic dilemmas, and variable treatment strategies are being found in the literature. In our opinion, the same basic principles used for treatment of cancers of the orthotopic breast should be applied in ectopic breast carcinoma.

Cold knife conization and loop excision for cervical intraepithelial neoplasia.

AIMS AND BACKGROUND: Our aim was to investigate whether loop excision is an acceptable alternative to traditional cold knife conization of the cervix. PATIENTS AND METHODS: 240 with cervical intraepithelial neoplasia (CIN) were randomly assigned to loop excision (n = 120) or cold knife conization (n = 120). Success and complication rates of both methods were analysed. RESULTS: 100% of cold knife conization and 98% of loop excision surgical specimens were positive for dysplasia. The rate of complete resection was 91% in the cold knife and 82% in the loop excision group, but histologic confirmation of residual CIN was obtained in only 2 (1.7%) women after cold knife conization and in 5 (4.2%) after loop excision. Loop excision cones were significantly shallower than those obtained by a cold knife. Secondary surgical procedures due to early hemorrhage were performed in 9 (7.5%) patients treated with cold knife conization and in 8 (6.7%) treated with loop excision. Elevated temperature postoperatively was observed in 16.4% of patients after cold knife conization and in 13.9% after loop excision. There were no other postoperative complications. CONCLUSIONS: The results suggest that cold knife conization and loop excision are comparable and equally effective diagnostic and therapeutic procedures for CIN.

Pelvic actinomycosis.

Pelvic actinomycosis is a rare chronic infection caused by bacteria of the family Actinomycetaceae. Prolonged use of an intrauterine contraceptive device (IUD) is a well known risk factor. We report six patients with pelvic actinomycosis, all of whom had an IUD inserted for over six years. Diagnostic problems necessitated a laparotomy in all patients. The pathohistological diagnosis was based on the characteristic microscopic image and specific staining. The patients were treated with penicillin and amoxycillin for several months.

Chlamydia trachomatis infection in women with and without cervical intraepithelial neoplasia.

The aim of the study was to compare the frequency of Chlamydia trachomatis infection in patients with cervical intraepithelial neoplasia (CIN) and in women without cervical pathology. In a study group of 423 patients with histologically proven CIN and in 108 controls with normal cervical smear, cytological material for direct immunofluorescence analysis was obtained. Among 423 patients, 24 (5.7%) had CIN 1, 108 (25.5%) CIN 2 and 291 (68.8%) CIN 3. Among all patients with CIN, 27 (6.4%) were C. trachomatis positive and 396 (93.6%) C. trachomatis negative. In the control group 6 (5.6%) were C. trachomatis positive and 102 (94.4%) C. trachomatis negative. The difference between C. trachomatis infection incidence in patients with CIN and in women without cervical pathology was not significant (chi2=0.29; P>0.05). In this study, no difference in C. trachomatis infection incidence was detected between patients with CIN and women with normal cervical smears. The impact of C. trachomatis infection seems not to interfere with the development or even the promotion of CIN.

User friendly inquiry and computer program for following patients with ovarian malignancy.

The establishing of a correct diagnosis in patients with ovarian malignancy requires the combination of a variety of methods of examination. An inquiry for following of malignoma patients has been compiled, accompanied by an adequate computer program. Beside general information regarding the patient, diagnosis and treatment, the inquiry also includes the case history, data regarding clinical, ultrasonographic and preoperative examinations, surgery, histologic findings and follow-up after termination of treatment. A user-friendly computer program was developed for recording and processing of all available data collected during the diagnostic and treatment procedures. The inquiry and the computer program have been in use for three years and we find they are very useful in follow-up of patients with ovarian malignancy. Data are collected at one site, transparent and always available. Statistical analysis of collected data can be performed by computer. The aim of this uniform inquiry and computer program is a concurrent, radical and simplified collecting, processing and comparing of data at each center and between centers dealing with the treatment of ovarian malignancy.

The frequency of Chlamydia trachomatis infection in women with intraepithelial neoplasia of the uterine cervix.

OBJECTIVE: To evaluate the frequency of Chlamydia trachomatis (CT) infection in patients with cervical intraepithelial neoplasia (CIN) referred for conisation. METHODS: 423 patients with histologically proven CIN were included in this study. Before conisation, cytological material for direct immunofluorescence analysis was obtained. The incidence of CT in cytologic smears of all three CIN groups was calculated. RESULTS: Among all patients with CIN, 27 (6.4%) were CT positive and 396 (93.6%) CT negative. There were 2 (8.3%) CT positive patients with CIN 1, 10 (9.3%) with CIN 2 and 15 (5.2%) with CIN 3. The difference between CT infection incidence in patients with CIN 1 and CIN 2 was not significant; neither was it significant between patients with CIN 1 and CIN 3 nor between those with CIN 2 and CIN 3. CONCLUSIONS: Chlamydia trachomatis infection in patients with CIN is not very common. The impact of CT infection does not seem to interfere with development or even promotion of CIN.

[The thrombocytopenia syndrome caused by heparin]. / Sindrom trombocitopenije izazvane heparinom.

Heparin represents the basis for drug treatment and prevention of thrombosis. However, heparin itself may produce side effects, among others two types of heparin-induced thrombocytopenia (HIT). The more frequent type 1 occurs in about 10% of patients within the first days of the treatment and disappears spontaneously without sequelae. HIT type 2 represents a far more serious complication occurring in 0.1-1% of patients somewhat later, between days 4 and 10 of heparin therapy, and may provoke severe arterial and venous thrombosis. Apart from the differences in clinical picture, data regarding platelet count and platelet aggregation test are significant for the diagnosis. Heparin should be discontinued immediately and another anticoagulant therapy introduced. We are presenting the case of a patient with thrombosis of the left external iliac artery following surgery for ovarian cancer as a complication of HIT type 2, which was recanalized successfully and the leg was saved.

Human papillomavirus 16 and 18 infection of the uterine cervix in women with different grades of cervical intraepithelial neoplasia (CIN).

OBJECTIVE: To evaluate the frequency of human papillomavirus (HPV) 16 and 18 infection in patients with different grades of cervical intraepithelial neoplasia (CIN). METHOD: Five-hundred and five patients with CIN, referred for conization, were included in this study. Before conization, cytological material for in situ hybridization was obtained from the uterine cervix to detect the presence of HPV 16 and 18 infection. RESULT: Among all patients with CIN, 82 (16.2%) were solely HPV 16 and 51 (10.1%) were solely HPV 18 positive. There were 133 patients (26.3%) positive for HPV 16 or HPV 18 and 31 patients (6.1%) were positive for both viral types, giving an overall HPV 16/18 infection rate of 32.4%. There were 15 (55.5%) HPV 16 or HPV 18 positive patients with CIN 1, 45 (33.8%) HPV 16 or HPV 18 positive patients with CIN 2 and 104 (30.2%) HPV 16 or HPV 18 positive patients with CIN 3. CONCLUSION: In patients with CIN 1, HPV 16 and 18 infection was more frequent than in patients with CIN 2, but the difference was not significant. Patients with CIN 2 were infected slightly more frequently, but not significantly, than patients with CIN 3. On the other hand, patients with CIN 1 were significantly more frequently infected than patients with CIN 3.

C-reactive protein and the treatment of pelvic inflammatory disease.

OBJECTIVE: The significance of C-reactive protein (CRP) in assessing the treatment of pelvic inflammatory disease (PID) was established and compared with body temperature (BT), erythrocyte sedimentation rate (ESR) and serum leukocyte concentration (L). METHOD: In 51 patients with PID, 20 (39%) of them with tubo-ovarial abscess (TOA), measurement of BT and laboratory investigations were carried out on admission and during treatment on days 3-4, 6-8 and 18-21. The changes in these values were compared with the changes in clinical condition. RESULT: Prior to treatment, the majority--49 patients or 96.1%--had increased CRP values. In successful treatment, the CRP values decreased significantly in PID patients without TOA on day 3-4, in patients with TOA on day 6-8 and reached normal values in both groups on day 18-21. Changes in clinical condition were most concurrent with changes in CRP. CONCLUSION: In assessing PID treatment, the determination of CRP has precedence over L, ESR and BT as the percentage of patients with increased CRP is higher and because the changes in value follow the changes in clinical condition more reliably.

Malignant acanthosis nigricans and tripe palms in a patient with endometrial adenocarcinoma--a case report and review of literature.

BACKGROUND: In the world literature, uterine carcinoma associated with paraneoplastic malignant acanthosis nigricans and tripe palms has been mentioned in two review articles. Endometrial adenocarcinoma associated with malignant acanthosis nigricans without tripe palms has been cited in three case reports, and endometrial adenocarcinoma associated with tripe palms without malignant acanthosis nigricans has been cited in one case report. We present the case of a patient with endometrial adenocarcinoma associated with acanthosis nigricans and tripe palms which we have been following for the past 7 years. METHODS: Our 54-year-old patient had been operated for moderately differentiated endometrial adenocarcinoma. She had also received postoperative radiotherapy. RESULTS: Three years after surgery, tripe palms and acanthosis nigricans with generalized pruritus occurred. After treatment with etretinate, the skin symptoms were somewhat mitigated while the pruritus persisted. Six years after gynecologic treatment, a solitary inguinal metastatic lymph node of endometrial carcinoma was detected. Following lymphadenectomy there was additional but not complete mitigation of skin symptoms including pruritus. CONCLUSIONS: In clinical practice the association of malignant acanthosis nigricans and tripe palms with endometrial adenocarcinoma is found extremely rarely. Although the survival time of adenocarcinoma patients with malignant acanthosis nigricans is short, our patient has been treated and followed for more than 7 years.

Preoperative value of CA 125 as a reflection of tumor grade in epithelial ovarian cancer.

A retrospective study of 60 patients with invasive epithelial ovarian cancer was conducted. The significance of preoperative serum CA 125 level with respect to tumor grade and tumor stage was determined. Tumor grade bears a strong influence on the preoperative CA 125 level; the correlation is high and statistically significant (r = 0.74, P < 0.01). The influence of FIGO stage on preoperative CA 125 level is also significant (r = 0.51, P < 0.01), but the results of the multivariate analysis show that the influence of tumor grade on preoperative CA 125 level is stronger (P < 0.01). It is believed that tumor grade is the decisive factor dictating the level of CA 125 in a certain stage of the disease and so influences the preoperative CA 125 level. It is also believed that low preoperative antigen levels of well-differentiated ovarian carcinomas in FIGO stage I are the cause of poor sensitivity of the CA 125 test, thus limiting its applicability for screening purposes.

Low doses of heparin and heparin dihydergot in postoperative thromboprophylaxis in gynaecological patients.

A prospective study of postoperative thromboembolic prophylaxis involving 500 gynaecological patients was performed to compare the effectiveness and safety of low doses of heparin (LDH) and heparin-dihydergot (HDHE). In the LDH group 255 patients (51%) aged 26-84 were included, in the HDHE group there were 245 patients (49%) aged 34-86. Both groups were well matched with respect to risk factors, duration of surgery, type of operation, volume of blood transfused and duration of prophylaxis. Thromboembolism was detected in 48 patients (9.6%): 26 patients (10.2%) in the LDH group and 22 patients (9%) in the HDHE group. In the LDH group isotopic deep vein thrombosis (DVT) was found in 23 patients (9%), five of them had pulmonary embolism (PE), detected by lung perfusion scanning without clinical signs of PE, three patients developed clinical PE without detected DVT. In the HDHE group, 22 patients (9%) had isotopic DVT and five of them had PE detected by lung perfusion scanning. In the incidence of TE there was no statistically significant difference between the two groups (p > 0.1). Within two months after surgery late clinically manifest TE confirmed by isotopic venography developed in five patients (1.9%) in the LDH group and in one patient (0.4%) in the HDHE group. Wound haematomas appeared in 8 patients (3.1%) in the LDH group and in 9 patients (3.7%) in the HDHE group. There were no ischemic complications (ergotism) in the HDHE group. The HDHE prophylaxis proved no more effective and was ten times more expensive than the usual prevention with LDH.

Prevention of postoperative thromboembolism in gynaecological malignancy.

A prospective randomized clinical trial compared the efficacy of low doses of heparin (LDH) and heparin plus dihydroergotamine mesylate (HDHE) in the prevention of thromboembolism in gynaecological patients with malignancy undergoing major surgery. One hundred and fifty-five patients, with a mean age 54.5 years were allocated to receive 5,000 IU unfractionated heparin or 5,000 IU unfractionated heparin +0.5 mg dihydroergotamine mesylate twice daily. Treatment was begun 2 hours preoperatively and continued until discharge (12 +/- 7 days). The incidence of thromboembolism determined by radiolabelled fibrinogen and lung perfusion scanning was 21.3% in LDH group and 22.7% in HDHE group. There were no statistically significant differences between the two groups (p > 0.1). The observed haemorrhagic rate was 1.9% in both groups. HDHE prevention was more expensive but without significant advantage over LDH. During two months after surgery 4 patients (5%) in the LDH group and 1 patient (1.8%) in the HDHE group developed deep vein thrombosis.

[Reconstruction after radical vulvectomy]. / Rekonstruckcije nakon radikalne vulvektomije.

From 1981-85, 29 patients with vulvar cancer were operated on. In 19 patients transplants and the transposition and rotation of local flaps were used. Merely in two patients was there minimal dehiscence and the average period of hospitalization amounted to 29 days.

[Diagnosis of breast cancer in the gynecology department]. / Dijagnostika raka dojke na ginekoloskom odjelu.

Breast examinations were performed in 4199 women by a simultaneous carrying out of clinical investigation, thermography and mammography, and, if needed, also by ultrasonic examination and aspiration cytology. A total of 169 women were referred to treatment and biopsy. Among them, 78 had breast cancer. In 6 patients ca in situ intraductale was discovered, while the disease was limited to the breast with negative lymph nodes in the axilla in 48 (61.5%) patients. Mammography proved more successful than clinical investigation. Its sensitivity amounted to 92% and that of clinical investigation only to 69%. The cost of a complete diagnostic process (on the first of April, 1986) was 5.717 dinars, which means that the cost of a diagnosed carcinoma was 307.765 dinars.