Does hysteroscopy affect prognosis in apparent early-stage endometrial cancer?

The objective of the study was to compare the outcome measures of patients with endometrial adenocarcinoma diagnosed by endometrial biopsy, uterine curettage, or hysteroscopy. Medical records of 392 women diagnosed with apparent early-stage endometrial adenocarcinoma were reviewed. Data concerning the mode of diagnosis, histologic type and grade, surgical stage, peritoneal washings and lymph nodes status, and patient's outcome were retrieved. During the study period, 99 (25.3%) cases were diagnosed by endometrial biopsy, 193 (49.2%) by uterine curettage, and 100 (25.5%) by hysteroscopy. There were 347 (88.5%) cases of endometrioid adenocarcinoma and 45 (11.5%) of poor histologic types, including serous papillary, clear cell, and small cell cancer. Three hundred and sixteen (80.6%) patients had stage I disease, 8 (2.0%) stage II, and 68 (17.4%) stage III. Peritoneal cytology was positive in only one case. Recurrent disease occurred in 6.9% patients, of which 50% had local recurrence and 50% had distant. Recurrent disease was found in 15.2% patients diagnosed by endometrial biopsy, in 4.7% where uterine curettage was used, and in 5% when hysteroscopy was applied. No statistically significant difference in the survival rate between the different diagnostic methods applied was found, although a higher recurrence rate was noted following endometrial biopsy. After a median follow-up time of 25 months for patients undergoing hysteroscopy, there was no difference in recurrence rates and/or overall survival compared to other diagnostic procedures implying that hysteroscopy can be safely used in the diagnosis of endometrial cancer.

[Survey of patient satisfaction at the Yad Sarah Geriatric Dental Clinic].

OBJECTIVES: The purpose of this study is to determine the influence of a supporting professional environment, in a voluntary dental clinic, on the satisfaction among dental patients. METHODS: A sample of 109 patients who received dental care between 3/01-3/02 at the Yad Sarah dental clinic in Jerusalem were asked about : their satisfaction concerning their experience of previous visits, the frequency of their visits, how they heard about the clinic and whether they would return to the clinic in the future. RESULTS: On average, each patient visited the clinic three times. 36.7% of the patients heard about the clinic from friends or family. Most of the patients were highly satisfied (47.2%) or satisfied (36.1%) with the clinic. The two best predictors of patient satisfaction (total 83.2%) were the professionalism of the dentists (41.4%) and the good attitude of the dentists to them. On the other hand, the two best predictors of patient non-satisfaction (14%) were the low professionalism of the dentists (33.3%) and the price of the treatments at the clinic (33.3%). 89% said they would return to the clinic and 93% said they would recommend that other patients use the services of Yad Sarah dental clinic. CONCLUSIONS: Overall, the patients who were treated at the Yad Sarah dental clinic expressed high levels of satisfaction with the care they received. The professionalism and the attitude of the staff were the main contributors to the high level of satisfaction with the Yad Sarah dental clinic.

Dermatomyositis following the diagnosis of ovarian cancer.

We present a case history of a woman who developed dermatomyositis following the diagnosis of stage IV ovarian cancer. Dermatomyositis is a rare paraneoplastic syndrome that usually precedes the diagnosis of ovarian cancer by several months or years. Ours is the fifth reported case of dermatomyositis after an established diagnosis of ovarian cancer in the literature.

A multicenter study of CA 125 level as a predictor of non-optimal primary cytoreduction of advanced epithelial ovarian cancer.

AIMS: To provide a large database of pre-operative CA 125 levels which may predict inappropriate cytoreductive surgery in patients with advanced epithelial ovarian cancer. METHODS: A multicenter review of the records of 424 patients with FIGO stage III and IV epithelial ovarian cancer of patients who underwent primary cytoreductive surgery was performed. The validity of pre-operative CA 125 level measurement as a single predictor of the possibility to achieve only suboptimal cytoreduction was evaluated by calculating the sensitivity and the specificity of various cut-off values. The relative importance of different cut-off values in achieving the best predictive validity was assessed by a receiver operating characteristics (ROC) curve. RESULTS: Optimal cytoreduction (largest diameter of residual tumour < or =1 cm) was achieved in 242 patients. The median CA 125 level in optimally cytoreduced patients was lower than in those patients suboptimally debulked (304 vs 863 U/mL; p<0.001). The area under the ROC curve was 0.65 (95% confidence interval, 0.60-0.71) and the CA 125 threshold derived from the ROC was 400 U/mL. The accuracy of the test at this level was 62%. CONCLUSIONS: The clinical applicability of the ROC derived CA 125 threshold is limited. The data accrued in the study provides a basis for decision-making regarding the place of primary surgery various CA 125 levels.

Trophoblastic peritoneal implants after laparoscopic treatment of ectopic pregnancy.

Persistent trophoblastic activity after salpingostomy for ectopic pregnancy implies the presence of intra-abdominal trophoblastic tissue, usually within the fallopian tube. We report a case of disseminated trophoblastic peritoneal implants, presenting as hemoperitoneum three weeks after laparoscopic salpingectomy. Only 23 such cases have been reported. Surgical treatment of ectopic pregnancy, especially by the laparoscopic technique, may cause intraperitoneal spread and reimplantation of trophoblastic tissue. Precautions for minimizing this complication are discussed.

Elevated serum alkaline phosphatase may enable early diagnosis of ovarian cancer.

A case of endometrioid ovarian carcinoma associated with elevated levels of serum placental-like alkaline phosphatase (PLAP) is presented. Two and a half years before a final diagnosis was made following explorative laparotomy, an incidental blood test revealed elevated alkaline phosphatase in the patient's serum. A thorough investigation for the source of this elevation was negative. Postoperative immunohistochemical staining of the tumor, showed diffuse stain with PLAP, along with gradual decline to normal values of serum total alkaline phosphatase. It is suggested, that whenever serum alkaline phosphatase is elevated due to unknown reason, an investigation including alkaline phosphatase isoenzymes, serum Ca-125, trans-vaginal pelvic sonogram and even diagnostic laparoscopy, should be considered in a search for early preclinical ovarian cancer.

Malignant melanoma of the vulva: report of six cases and review of the literature.

Six patients with vulvar malignant melanoma are reported. They accounted for 5.2% of all females with vulvar malignancies diagnosed in the south of Israel between 1961 and 1997. Age ranged from 25 to 66 years. Presenting symptoms were pruritus, bleeding and ulcer. Lesion originated in the labia minora in four patients and the labia majora in two, and lesion size ranged from I to 8 cm. Five patients had nodular melanoma, and one had superficial spreading melanoma. Breslow depth ranged from 2.5 to 8 mm, Clark level was IV in four patients and III in two, and Chung level was IV in all patients. Two patients had radical vulvectomy and bilateral groin lymphadenectomy, one had wide local excision, and one refused surgery. The two patients who had radical hemivulvectomy and bilateral groin lymphadenectomy were given adjuvant active specific immunotherapy with allogeneic vaccine and have survived disease-free, whereas the remaining four patients died of disease. It is concluded that vulvar malignant melanoma is a rare and aggressive tumor. For patients who present with deep lesions (Breslow depth > 0.76 mm, Clark level > II, Chung level > II) the recommended treatment is wide radical local excision (or at the most, radical hemivulvectomy) and bilateral groin lymphadenectomy.

Extramammary Paget's disease of the vulva: report of five cases and review of the literature.

Five patients with vulvar extramammary Paget's disease (EMPD) are reported. They accounted for 4.4% of all vulvar malignancies diagnosed in the south of Israel between 1961-1997. Mean age was 64.4 years and the predominant symptom was vulvar pruritus. Three patients had intra-epidermal lesions (managed by wide local excision or, at most, simple vulvectomy), one had a minimally invasive lesion (managed by simple vulvectomy) and one had EMPD with an underlying apocrine gland adenocarcinoma (managed by radical vulvectomy and bilateral groin dissection followed by pelvic radiotherapy). EMPD recurred in two patients: 1) local recurrence after simple hemivulvectomy for an intra-epidermal lesion was successfully treated by wide local excision; 2) widespread recurrence at distant skin sites after simple vulvectomy for a minimally invasive lesion was unsuccessfully treated with systemic chemotherapy. It is concluded that vulvar EMPD is an uncommon neoplasm that primarily affects postmenopausal women. Its histogenesis is uncertain and most commonly it is an intra-epidermal lesion. The high rate of recurrent disease remains a challenge for optimal management.

Diagnostic dilemmas and current therapy of Fallopian tube cancer.

Primary tubal cancer, unlike ovarian cancer, is not routinely suspected preoperatively, and thus diagnosis and therapy are delayed. We have recently encountered two cases in which primary Fallopian tube cancer masqueraded as other lesions. One presented as a pelvic inflammatory process, the second as cervical cancer. Primary Fallopian cancer should be suspected by the clinician, even if the presenting symptoms are atypical. Chemotherapy with taxol and cisplatin was instituted following debulking surgery.

Conservative treatment of adenocarcinoma of the endometrium in young patients. Is it appropriate?

Few reports have suggested that nulliparous young patients with endometrial cancer may be treated conservatively to preserve fertility. We present a young nulliparous woman with a well differentiated adenocarcinoma of the endometrium treated with progestins. Since she did not respond, a definite operation was performed revealing involvement of the uterine isthmus, thus necessitating adjuvant radiotherapy.

Basal cell carcinoma of the vulva.

BACKGROUND AND OBJECTIVES: Vulvar basal cell carcinoma (BCC) accounts for 7% of all vulvar cancers at two hospitals in the south of Israel. The purpose of this study was to investigate the clinical findings, treatment and outcome of patients with vulvar BCC treated at these institutions. METHODS: Data from the files of eight patients with vulvar BCC who were managed at two regional hospitals in the south of Israel (Soroka Medical Center, Beer-Sheva and Kaplan Hospital, Rehovot) between January 1961 and December 1997 were evaluated. RESULTS: Mean age at diagnosis was 70.5 years. A history of other primary cancers was encountered in two patients. Prevailing presenting symptoms were vulvar lump, ulcer, itching, and bleeding. The tumor was most often located on the labium major and its mean size was 2.25 cm. Six patients had wide local excision, one had excisional biopsy, and one had hemivulvectomy. Two patients developed local recurrence and were treated by wide local reexcision and hemivulvectomy, respectively. At follow-up, no patient developed regional and/or distant metastases, or died of BCC. CONCLUSIONS: Vulvar BCC is characterized by an indolent behavior with a very low propensity for metastatic spread. The treatment of choice is wide local excision. Because of a substantial risk of local recurrence and high frequency of other primary cancers, close long-term follow-up is essential.

Sertoli cell tumor causing precocious puberty in a girl with Peutz-Jeghers syndrome.

Distinctive ovarian and cervical tumors are associated with Peutz-Jeghers syndrome (PJS). The most common gynecological tumors in this syndrome are adenoma malignum of the uterine cervix and ovarian sex cord tumor, particularly sex cord tumor with annular tubules (SCTAT). Other kinds of ovarian tumors have been rarely reported in association of PJS, including Sertoli cell tumors. We report a case of a 4.5-year-old girl with PJS who presented with isosexual precocious puberty (IPP) due to ovarian lipid-rich Sertoli cell tumor. In addition to estrinizing effect of the tumor, the patient had decidual reaction secondary to tumor-derived progesterone secretion. The literature on gonadal tumors in PJS is reviewed, including one previous report of ovarian lipid-rich Sertoli cell tumor associated with this syndrome.

Uterine papillary serous carcinoma: study of 19 cases.

OBJECTIVE: Uterine papillary serous carcinoma (UPSC) is an uncommon highly malignant variant of endometrial carcinoma that histologically and clinically resembles ovarian papillary serous carcinoma. The purpose of this study was to present the conjoined experience of two regional hospitals in the south of Israel (Soroka Medical Center, Beer-Sheva and Kaplan Hospital, Rehovot) of handling this tumour. STUDY DESIGN: Data from the files of 19 patients with UPSC who were managed at these hospitals between July 1991 and June 1997 were evaluated. RESULTS: The three-year survival rate was 57.3% overall; 83.3% for Stage I and 21.2% for Stages II, III, and IV combined (P<0.02). Eighteen patients had primary surgery which included total abdominal hysterectomy and bilateral salpingo-oophorectomy and 15 (83.3%) of them received postoperative adjuvant therapy which included radiotherapy and/or systemic chemotherapy. CONCLUSIONS: The prognosis of patients with UPSC is worse than that of patients with other forms of endometrial carcinoma. Primary surgery comprised of total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging is the mainstay of treatment. The type of postoperative treatment is not consistent. By and large, adjuvant pelvic radiotherapy is usually given in early-stage disease and adjuvant systemic chemotherapy is usually prescribed in advanced-stage disease.

Clinical-pathological study of uterine leiomyomas with high mitotic activity.

OBJECTIVE: To evaluate clinical-pathological aspects of mitotically active leiomyomas. STUDY DESIGN: Twenty patients with smooth muscle tumors of the uterus, with 5-9 mitotic figures per 10 high power fields and without atypia or necrosis were studied. The clinical and pathological characteristics of these tumors were reviewed and analyzed. RESULTS: Patients' ages ranged from 33 to 63 years (mean 42.5 years). The size of the tumors ranged from 1.5 to 9.5 cm (mean 5.4 cm). On gross examination all tumors appeared as typical leiomyomas. Treatment included hysterectomy in 16 patients and myomectomy in four. Follow-up periods ranged from 1.5 to 11 years (mean 6.8 years). None of the patients developed a recurrent tumor. CONCLUSION: The benign clinical behavior of such tumors supports their current designation as mitotically active leiomyomas, thus deleting the previous misnomer 'smooth muscle tumors of uncertain malignant potential'. Myomectomy is an appropriate treatment, particularly in young patients interested in reproduction.

Unsuspected uterine leiomyosarcoma discovered during treatment with a gonadotropin-releasing hormone analogue: a case report and literature review.

We report a case of a 37-year-old woman who had received five courses of gonadotropin-releasing hormone (GnRH) agonist (Decapeptyl) for presumed uterine leiomyomata associated with episodes of uterine bleeding. Submucous myoma (histologically proven) was partially removed on the first visit. After a period of significant reduction in the tumor size and cessation of uterine bleeding, the symptoms recurred along with rapid re-growth of the uterus. Total abdominal hysterectomy was performed and the pathologic evaluation revealed leiomyosarcoma with a high mitotic rate. This case and the literature review emphasize the problems encountered with the early diagnosis of uterine leiomyosarcoma during GnRH agonist therapy.

Gestational trophoblastic disease following the evacuation of partial hydatidiform mole: a review of 66 cases.

OBJECTIVE: The current study was undertaken in order to identify the clinical characteristics and natural history, as well as methods of investigation and available therapy, of persistent gestational trophoblastic disease (GTD) following the evacuation of partial hydatidiform mole (PM). METHODS: Case reports of persistent GTD following the evacuation of partial mole, were searched using the Medline computerized retrieval system. There were 66 such cases (including 4 cases treated at our department), representing 2.9% of GTD following PM. RESULTS: The mean age of the women at diagnosis was 28.4 years and mean gravidity was 2.99. The mean gestational age at diagnosis was 15.5 weeks and the mean uterine size was 13.6 weeks. The most common presenting symptom was vaginal bleeding. In the majority of the patients, the pre-evacuation diagnosis was incomplete or missed abortion. CONCLUSIONS: Although the malignant potential of PM is low, persistent GTD may develop after PM and may even metastasize, it is usually responsive to single agent chemotherapy but may require combination chemotherapy. Therefore, after evacuation of PM, these women should be followed with serial serum b-hCG. Further research is needed to enable earlier identification of PM that eventually will develop persistent GTD.