Single-agent chemotherapy in low-risk gestational trophoblastic neoplasia.

Background: Low-risk gestational trophoblastic neoplasia could be cured in the case of appropriate management with single-agent chemotherapy. This study was carried out to compare the efficacy of single-dose methotrexate versus Actinomycin-D in low-risk gestational trophoblastic neoplasia to analyze the most effective agent. Methods: This retrospective cohort study was conducted on the medical record of 170 cases with the diagnosis of low-risk gestational trophoblastic neoplasia from 2012 to 2019 to evaluate the response rate of single-dose weekly-methotrexate versus biweekly-Actinomycin-D. Results: Single agent chemotherapy was required in 170 patients with final risk score of less than 7. Among the 100 cases under weekly-methotrexate therapy, 29 patients were required second-line chemotherapy with Actinomycin-D and combination therapy which means complete remission of 71% with methotrexate, in comparison with 78.5% in the other group. Resistance was mostly seen in patients with documented choriocarcinoma in histology who had not received timely diagnosis and treatment. Conclusion: Individualized decision in the management of low-risk gestational trophoblastic neoplasia cases, based on histology, HCG, and history is the corn stone in successful treatment.

Molar Changes With a Normal Viable Fetus: A Case Report.

Objective: The presence of a normal fetus with normal karyotype accompanied by molar changes in the placenta is a rare condition, which carries a significant risk to the mother and fetus. There is a controversy regarding the proper management of this condition. Here, we present the case of a singleton pregnancy that showed molar changes in the pathological study of the placenta, but ended up with a normal viable neonate. Case Report: A 23-year-old primigravida woman, with a 3-year history of infertility, presented with vaginal bleeding and spotting. Her ß-human chorionic gonadotropin (HCG) at 13th week was 36500 mIU/ml. Serial sonography assessments were suggestive for molar changes and a normal fetus with growth retardation but normal Doppler assessment. The patient underwent elective Cesarean section at 37 weeks gestation and a healthy female neonate with an Apgar score of 9-10, weighing 2270 g was born. Pathological assessment of the placenta confirmed the diagnosis of incomplete hydatidiform mole. After two months, the mother had no complications, her ß-HCG level was untraceable, and the infant was in good condition. Conclusion: Despite being a rare condition, partial moles can be accompanied by delivery of a normal fetus. The management of this condition still remains challenging and should be done under close monitoring with extreme caution.

Concordance Between Intracervical and Fundal Injections for Sentinel Node Mapping in Patients With Endometrial Cancer?: A Study Using Intracervical Radiotracer and Fundal Blue Dye Injections.

OBJECTIVE: A major controversy in sentinel node (SN) biopsy of endometrial cancer is the injection site of mapping material. We compared lymphatic drainage pathways of the uterine cervix and uterine body in the same patients by head-to-head comparison of intracervical radiotracer and fundal blue dye injections. METHODS: All patients with pathologically proven endometrial cancer were included. Each patient received 2 intracervical injections of Tc-phytate. At the time of laparotomy, the uterus was exposed, and each patient was injected with 2 aliquots of patent blue V (2 mL each) in the subserosal fundal midline locations. The anatomical locations of all hot, blue, or hot/blue SNs were recorded. RESULTS: Overall, 45 patients entered the study. At least 1 SN could be identified in 75 of 90 hemipelves (83.3% overall detection rate, 82.2% for radiotracer [intracervical] alone, and 81.1% for blue dye [fundal] alone). In 71 hemipelves, SNs were identified with both blue dye (fundal) and radiotracer (intracervical) injections. In 69 of these 71 hemipelves, at least 1 blue/hot SN could be identified (97.18% concordance rate). In 10 patients, para-aortic SNs were identified. All of these nodes were identified by fundal blue dye injection, and only 2 were hot. CONCLUSIONS: Our study shows that lymphatic drainage to the pelvic area from the uterine corpus matches the lymphatic pathways from the cervix, and both intracervical and fundal injections of SN mapping materials go to the same pelvic SNs.

Granulosa-cell tumor after ovarian stimulation: A case report.

BACKGROUND: Ovarian superovulation and increased follicle-stimulating hormone concentration for infertility treatment may be the risk factors of developed granulosa-cell tumor. The aim of this report is to introduce a case of granulosa-cell tumor which was discovered after ovarian stimulation. CASE: A 31-yr-old woman with clinical presentation of massive abdominal distention was referred to the gynecology and oncology department of an academic hospital, Mashhad University of Medical Sciences in Aug 2017. She had the history of secondary infertility and was undergoing In Vitro Fertilization protocol and ovarian stimulation, but, the cycle was canceled. The patient suffered from gradual abdominal distention one month after the end of IVF procedure despite pregnancy failure. 2-3 months after management of the ovarian hyperstimulation syndrome, investigation revealed large ovarian mass and increased tumor marker inhibin. Exploratory laparotomy was performed and revealed stage III ovarian cancer. The final pathology report indicated juvenile granulosa cell tumor. So, optimal surgical staging and cytoreductive surgery without fertility preserving were perfumed. Chemotherapy was recommended due to the advanced stage of ovarian cancer. Unfortunately, she experienced metastatic diseases in pelvic and abdomen in less than six months; and currently is receiving the second and third line chemotherapy. CONCLUSION: Persistent ovarian enlargement or ascites during or after infertility treatment should be carefully considered and managed.

Effect of Combination Therapy of Methotrexate with Vitamin A in Patients with Low Risk GTN (Gestational Trophoblastic Neoplasia).

Methotrexate as a single agent chemotherapy in most women with low risk gestational trophoblastic neoplasia (GTN) has been associated with high treatment rate. Combination of methotrexate with Vitamin A due to reduced number of chemotherapy regime courses is one of the treatment options for patients with low-risk GTN. Therefore, this study was performed with aim to determine the efficacy of combination therapy of Methotrexate with Vitamin A in low risk GTN treatment. This randomized clinical trial was performed on 49 patients with low risk gestational trophoblastic neoplasia. The treatment group (Group A = 19 cases) weekly received Methotrexate 50 mg/m2, and Vitamin A 200000 IU, intra-muscular, and the control group (Group B = 30 cases) only received Methotrexate 50 mg/m2 weekly. All patients were followed up for 8 weeks. Then, treatment outcomes were compared between two groups, and response to therapy was assessed in two groups by evaluation of HCG serum level. P < 0.05 was considered significant.Mean of B-HCG serum level after 4 weeks in Group A and Group B was 68.5 mIu/mL and 360 mIu/mL, respectively (P = 0.018), and after 8 weeks was 1 mIu/mL and 12 mIu/mL, respectively (P = 0.074). Combination therapy of Methotrexate and Vitamin A in low risk GTN is associated with shorter duration of chemotherapy.

Genetic susceptibility in cervical cancer: From bench to bedside.

Cervical cancer (CC) is the third most common malignancy in women globally, and persistent infection with the oncogenic human papillomaviruses (HPV) is recognized as the major risk factor. The pathogenesis of CC relies on the interplay between the tumorigenic properties of the HPV and host factors. Host-related genetic factors, including the presence of susceptibility loci for cervix tumor is substantial importance. Preclinical and genome-wide association studies (GWAS) have reported the associations of genetic variations in several susceptibility loci for the development of cervical cancer. However, many of these reports are inconsistent. In this review, we discuss the findings to date of candidate gene association studies, and GWAS in cervical cancer. The associations between these genetic variations with response to chemotherapy are also discussed.

Lymphatic mapping and sentinel node biopsy in ovarian tumors: a study using intra-operative Tc-99m-Phytate and lymphoscintigraphy imaging.

BACKGROUND: Experience on sentinel node mapping in ovarian tumors is very limited. We evaluated the sentinel node concept in ovarian tumors using intra-operativeTc-99m-Phytate injection and lymphoscintigraphy imaging. METHODS: Thirty-five patients with a pelvic mass due to an ovarian pathology were included in the study. The radiotracer was injected just after laparotomy and before removal of the tumor either beneath the normal cortex (10 patients) or in the utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum two injections of the radiotracer (25 patients). For malignant masses, the sentinel nodes were identified using a hand held gamma probe. Then standard pelvic and para-aortic lymphadenectomy was performed. In case of benign pathologies or borderline ovarian tumors on frozen section, lymphadenectomy was not performed. The morning after surgery, all patients were sent for lymphoscintigraphy imaging of the abdomen and pelvis. RESULTS: Sentinel node was identified only in 4 patients of the cortical injection group. At least one sentinel node could be identified in 21 patients of the sub-peritoneal group. Sentinel nodes were identified only in the para-aortic area in 21, pelvic/para-aortic areas in 2, and pelvic only area in 2 patients. Three patients had lymph node involvement and all had involved sentinel nodes (no false negative case). CONCLUSION: Sentinel node mapping using intra-operative injection of the radiotracer (in the utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum) is feasible in ovarian tumors. Technical aspects of this method should be explored in larger multicenter studies in the future.

Abnormal Presentation of Choriocarcinoma and Literature Review.

INTRODUCTION: Gestational trophoblastic neoplasms have highly been malignant potential, which usually occurred in child-bearing age women. Unusual feature of this malignancy would be rare, it was important to take in mind the possibility of GTN in different manifestation. Based on the above mentioned, the aim of this presentation would be the management and outcome of a case series of choriocarcinoma patients with abnormal manifestation. CASE PRESENTATION: We have presented four patients, first who initially manifestation with signs of septic shock, the second case with severe gastrointestinal hemorrhage, the third case with postpartum infection and the forth case was a postmenopausal bleeding patient. CONCLUSIONS: In case of metastatic choriocarcinoma with precise history, accurate diagnosis and appropriate treatment have led us to curable results.

Lymphatic mapping and sentinel node biopsy in endometrial cancer--a feasibility study using cervical injection of radiotracer and blue dye.

BACKGROUND: The aim of this study was to evaluate the feasibility and accuracy of sentinel lymph node (SLN) detection using preoperative lymphoscintigraphy and intra-operative gamma probe/blue dye for endometrial cancer patients. MATERIAL AND METHODS: Twenty four consecutive patients with endometrial cancer were recruited. All patients underwent lymphatic mapping and sentinel node biopsy using combined intracervical radiotracer and blue dye injections. Pelvic lymph node dissection was performed for all patients. Para-aortic lymphadenectomy was done in high risk patients. All SLNs were examined by frozen section and Hematoxylin and Eosin (H&E) permanent sections. RESULTS: Pre-operative lymphoscintigraphy showed at least one SLN in 21/24 patients. Intra-operatively, at least one SLN could be harvested by gamma probe and/or blue dye methods. A total of 95 SLNs were detected. Four SLNs were detected only by blue dye, 42 only by radiotracer, and 49 were hot/blue. Median number of SLN per patient was 3. Three patients had positive pelvic lymph nodes. All of them had positive SLN (no false negative case). Frozen section could identify SLN involvement in two of three patients with positive pathology. CONCLUSION: Lymphatic mapping and sentinel node biopsy is feasible and accurate in endometrial cancer patients using combined radiotracer and blue dye methods. Frozen section accuracy was lower and underscores the importance of expert pathologists for SLN mapping technique.

Peripheral primitive neuroectodermal tumor of the pelvis.

The primitive neuroectodermal tumor (PNET) belongs to a group of highly malignant tumors and is composed of small round cells of a neuroectodermal origin. Categorized in the same tumor family as Ewing sarcoma, the PNET is most likely to occur in bones and soft tissues. However, a small number of PNET cases arising in the pelvis have been reported as well. WE PRESENT THREE CASES OF PELVIC PNET: two cases in the ovary and one case in the broad ligament. The PNET often exhibits aggressive clinical behavior with worse outcomes than other small round cell tumors. The significant prognostic factors of the PNET include site of tumor, volume of neoplasm, and presence of metastasis. The treatment protocol is multimodal and includes local surgical treatment followed by chemotherapy. We herein describe three PNET cases as a rare entity in the pelvis. Pelvic PNETs should be included in the differential diagnosis of pelvic masses.

Pelvic kidney visualization on the lymphoscintigraphy images of a patient with uterine cervix cancer: importance of the delayed imaging.

We reported an unusual visualization of a pelvic kidney on the lymphoscintigraphy images of a patient with uterine cervix cancer, which was mistaken with para-aortic sentinel nodes. Delayed imaging clearly showed the nature of this activity. Our case underscores the importance of delayed pelvic lymphoscintigraphy imaging in the sentinel node mapping of gynecological cancers.

Inappropriate Intra-cervical Injection of Radiotracer for Sentinel Lymph Node Mapping in a Uterine Cervix Cancer Patient: Importance of Lymphoscintigraphy and Blue Dye Injection.

Herein, we report a case of sentinel lymph node mapping in a uterine cervix cancer patient, referring to the nuclear medicine department of our institute. Lymphoscintigraphy images showed inappropriate intra-cervical injection of radiotracer. Blue dye technique was applied for sentinel lymph node mapping, using intra-cervical injection of methylene blue. Two blue/cold sentinel lymph nodes, with no pathological involvement, were intra-operatively identified, and the patient was spared pelvic lymph node dissection. The present case underscores the importance of lymphoscintigraphy imaging in sentinel lymph node mapping and demonstrates the added value of blue dye injection in selected patients. It is suggested that pre-operative lymphoscintigraphy imaging be considered as an integral part of sentinel lymph node mapping in surgical oncology. Detailed results of lymphoscintigraphy images should be provided for surgeons prior to surgery, and in case the sentinel lymph nodes are not visualized, use of blue dye for sentinel node mapping should be encouraged.

Spontaneous uterine perforation caused by pyometra: a case report.

INTRODUCTION: Pyometra is an accumulation of purulent material or pus in the uterine cavity. Spontaneous perforation of uterus by pyometra is rare. This is a clinical presentation and management of a spontaneous perforation of uterine caused by pyometra. CASE PRESENTATION: This is a case report on spontaneously perforated associated with pyometra secondary to cervical malignancy. The patient underwent exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy. CONCLUSIONS: Spontaneous rupture of pyometra duo to cervical cancer in cases of acute abdomen in elderly patients should be considered.

Diagnostic performance of fluorine 18 fluorodeoxyglucose positron emission tomography imaging for detection of primary lesion and staging of endometrial cancer patients: systematic review and meta-analysis of the literature.

OBJECTIVES: Fluorine 18 fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) imaging has been used for staging of endometrial cancer. In the current study, we systematically searched the available literature on the accuracy of (18)F-FDG PET imaging for staging of endometrial cancer. METHODS: PubMed, SCOPUS, ISI Web of Knowledge, Science Direct, and Springer were searched using "endometr* AND PET" as the search terms. All studies evaluating the accuracy of (18)F-FDG PET in the staging of endometrial carcinoma were included. Statistical pooling of diagnostic accuracy indices was done using random-effects model. Cochrane Q test and I(2) index were used for heterogeneity evaluation. RESULTS: Sixteen studies (807 patients in total) were included in the meta-analysis. Sensitivity and specificity for detection of the primary lesions were 81.8% (77.9%-85.3%) and 89.8% (79.2%-96.2%); for lymph node staging were 72.3% (63.8%-79.8%) and 92.9% (90.6%-94.8%); and for distant metastasis detection were 95.7% (85.5%-99.5%) and 95.4% (92.7%-97.3%). CONCLUSIONS: Because of low sensitivity, diagnostic utility of (18)F-FDG PET imaging is limited in primary tumor detection and lymph node staging of endometrial cancer patients. However, high specificities ensure high positive predictive values in these 2 indications. Diagnostic performance of (18)F-FDG PET imaging is much better in detection of distant metastases. Larger studies with better design are needed to draw any more definite conclusion.

Lymphatic mapping and sentinel node biopsy in squamous cell carcinoma of the vulva: systematic review and meta-analysis of the literature.

OBJECTIVES: We reviewed the available literature on the accuracy of sentinel node (SN) mapping in the inguinal lymph node staging of vulvar squamous cell carcinoma (SCC). METHODS: Medline and SCOPUS were searched by using "sentinel AND vulv*" as key words. Studies evaluating the accuracy of SN mapping in the inguinal lymph node staging of vulvar SCC were included if enough data could be extracted for calculation of detection rate and/or sensitivity. Only studies validated by inguinal lymph node dissection were included for sensitivity meta-analysis. RESULTS: Forty-nine studies were included in the systematic review. Pooled patient and groin basis SN detection rates were 94.4% [92.4-95.9] and 84.6% [80.5-88], respectively. Pooled patient and groin basis sensitivity were 92% [90-95] and 92% [89-94], respectively (or 8% [5-10] and 8% [6-11] false negative rates). Pooled negative predictive values were 97% [96-98] and 98% [97-99] for patient and groin basis analyses respectively. SN detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and location of the tumor (midline vs. lateral tumors). Patients with palpable inguinal nodes had lower detection rate and sensitivity. CONCLUSION: SN mapping is an accurate method for inguinal node staging in vulvar SCC. Combining radiotracer and blue dye methods and excluding patients with palpable inguinal nodes result in the highest detection rate and sensitivity. For midline tumors possible false negative results of SN mapping should be taken into account.

Neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer during pregnancy: case report and review of literature.

For pregnant patients with cervical cancer, treatment recommendations are individualized and dependent on the stage of the disease, gestational age at the time of diagnosis, and the patient's desire as to the cosntinuation of the pregnancy. The aim of this study is to describe the outcome of neoadjuvant chemotherapy with radical surgery and pelvic lymphadenectomy in a woman with cervical cancer who wished to maintain her pregnancy. This is a report of a 26-week pregnant woman with locally advanced cervical cancer stage I(b2) (FIGO) who was successfully treated with neoadjuvant chemotherapy Paclitaxel plus platinum, followed by C/S and radical surgery. Her neonate was healthy and had no abnormalities. This case was the first cervical cancer during pregnancy that was treated using this method at the tumor clinic, Mashhad University of Medical Sciences, Iran. Neoadjuvant chemotherapy is an effort to allow time for the fetal to reach viability by preventing the progression of the disease.

Less radical surgery for patient with early-stage cervical cancer.

INTRODUCTION: Surgery in cervical cancer should be used with intention of cure. Radical abdominal trachelectomy is a feasible operation for selected patients with stage Iα-1ß cervical cancer which fertility can be preserved. CASE REPORT: A 30-years-old woman with squamous cell cervical cancer stage (1 A II) diagnosed at September 2011 expressed a wish for fertility-sparing treatment. Radical abdominal hysterectomy and pelvic and para-aortic lymphadenectomy were performed which showed no evidence of lymphatic metastasis. Subsequently, at last follow-up (5 months post-surgery), good oncologic outcomes were found after this procedure. This was the first case of fertility-sparing radical trachelectomy procedures performed at our institution. CONCLUSIONS: Trachelectomy represents a valuable conservative surgical approach for early stage invasive cervical cancer.

Accuracy of 18-F-FDG PET imaging in the follow up of endometrial cancer patients: systematic review and meta-analysis of the literature.

OBJECTIVES: We reviewed the available literature on the accuracy of 18-F-FDG PET imaging in the follow up of the endometrial cancer patients and presented the results in systematic review and meta-analysis format METHODS: Medline, SCOPUS, ISI web of knowledge, Springer, and Science direct were searched with "PET AND Endometr*" as key words. All studies that evaluated the accuracy of 18-F-FDG imaging in the follow up of treated endometrial carcinoma were included if enough data could be extracted for calculation of sensitivity and/or specificity. RESULTS: Eleven studies (541 patients in total) were included in the analysis. Pooled diagnostic indices (patient basis) for detection of overall recurrence were as follows: sensitivity 95.8% [92.2-98.1], specificity 92.5% [89.3-94.9], positive likelihood ratio (LR+) 9.53 [6.52-13.91], negative likelihood ratio (LR-) 0.075 [0.044-0.128], and diagnostic odds ratio (DOR) 204 [91.97-453.5]. 18-F-FDG performance was better in studies conducted by PET/CT as compared to PET. The treatment plan changed in 22-35% of the studied patients. CONCLUSION: 18-F-FDG PET is an accurate method for detection and localization of recurrence in post-therapy follow up of endometrial carcinoma. It can also change the treatment planning by localizing the recurrent lesions.