Vulvar granular cell tumor (ABRIKOSSOFF TUMOR); a tumor of vulva which is rare but needs care.

•Abrikossoff tumor is a rare tumor but not always benign.•Re-excission for positive margins in benign tumors may not be invariably necessary.•Cosmetic issues may play role in the treatment and follow-up in benign tumors.

Placental volume and vascularization flow indices by 3D power Doppler US using VOCAL technique and correlation with IGF-1, free beta-hCG, PAPP-A, and uterine artery Doppler at 11-14 weeks of pregnancy.

AIMS: The purpose of this study was to investigate correlations between first trimester placental volume (PV) and blood flow indexes (FIs), bilateral uterine artery pulsatility indexes, notching, and biochemical parameters: pregnancy-associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotropin (f-ß-hCG), and insulin-like growth factor-1 (IGF-1) to predict the high-risk pregnancies in the first trimester. METHODS: We prospectively examined 310 patients at 11-14 weeks of pregnancy using transabdominal 3D gray scale and power Doppler ultrasound for assessing PV, vascularization index, FI, and vascularization FI (VFI). The acquired volumes were analyzed using VOCAL™ imaging software. The results were correlated with biochemical parameters. RESULTS: We found significant correlations between PV and biochemical parameters, and between placental blood flow studies and other parameters. Finally, PV/crown-rump length so called the placental quotient is also related to both PAPP-A and VFI. CONCLUSIONS: Placental volumetry, uterine artery Doppler studies, blood flow calculations and biochemical parameters, such as f-ß-hCG, PAPP-A, and IGF-1 could be important in the early and rapid diagnosis of high-risk pregnancies. Thus, they may be useful in first trimester prediction of fetal growth restriction presenting with alterations in PV and vascularity.

Longitudinal examination of cervical volume and vascularization changes during the antepartum and postpartum period using three-dimensional and power Doppler ultrasound.

OBJECTIVE: To assess longitudinally the changes in cervical volume and vascularization during the peripartum period using three-dimensional ultrasound (3D US) and power Doppler and to determine whether these measures change with gestational complications. METHODS: Longitudinal measurements of cervical dimensions by transvaginal 3D US and power Doppler using the virtual organ computer-aided analysis program were performed at 11-14, 22-24, 32-34 weeks' gestation, and at 6 weeks' postpartum in 111 pregnant women. Comparisons were made between women who delivered at term (vs. preterm), nulliparous (vs. parous), with (vs. without) pre-eclampsia and those with (vs. without) gestational diabetes. RESULTS: After establishing reference values for each peripartum period for cervical volume, vascularization index (VI) and flow index (FI), we found that the 2(nd) and 3(rd) trimester volume, 2(nd) trimester FI and postpartum VI were different in nulli- vs. multiparous women. Volume and vascularization parameters were unaffected by preterm labor. Second trimester VI and vascularization flow index values were lower in pre-eclamptic vs. non-pre-eclamptic women (P<0.05), but unaffected by gestational diabetes. CONCLUSION: Cervical volume and vascularization parameters are not helpful in predicting preterm labor and gestational diabetes, but might be associated with pre-eclampsia.

The importance of severity of arthrosis for the reliability of bone mineral density measurement in women.

The objective of this study is to investigate the effect of the severity of degenerative changes on measurements of A-P lumbar spines BMD values and to determine the reliability of DEXA measurements associated with severity of the disease on A-P lumbar spines BMD values using DEXA. The measurements using DEXA were taken from L2-L4 spines and femoral neck of total 271 female cases. One hundred and ten of them had mild arthrosis (Group 0), and 69 had severe arthrosis (Group 1). Ninety-two cases without arthrosis were chosen as control group (Group 2). The cases with arthrosic changes were grouped according to their degree of severity of arthrosis. The groups were compared two by two and Tukey multiple comparison test was used for the analysis of the difference of the means of the groups. The mean age of cases was 61.79, 61.84, and 60.47, respectively. The average height was 157.26, 155.93, and 15.92 cm while the average weight was 69.21, 70.78, and 71.45 kg, respectively. The mean body mass index (BMI) was 0.00283, 0.00291, and 0.00293, respectively. L2-L4 A-P spinal BMD values were 0.9870, 0.9848, and 1.0836 g/cm(2) while the femoral neck BMD values were 0.7964, 0.8056, and 0.8223 g/cm(2), respectively. There was no statistical significance between study and control groups in terms of age, weight, height, BMI, and BMD values obtained from femoral neck. However, lumbar region BMD values of the cases with severe arthrosis were statistically significantly high when compared with other two groups. The femoral neck measurement is the prominent alternative method in severe arthrosis while taking measurements from lumbar region is still the most appropriate method in cases with mild arthrosis without having giant osteophytes.

The impact of clothing style on bone mineral density among women in Turkey.

To investigate the effect of veiled clothing style on bone mineral density (BMD). The BMD measurements were performed on the femoral neck and the lumbar spines of adult female population with two different types of clothing taking calcium daily in the normal range according to the proper technique utilizing dual energy X-ray absorptiometry (DEXA). In the lumbar spine measurements, the BMD was measured 1.0020 +/- 0.177 gr/cm2 in cases with veiled clothing style while it was measured 1.0793 +/- 0.169 gr/cm2 in cases with unveiled clothing style (P = 0.049, t = 1.98). In the femoral neck measurements, the BMD was measured 0.8428 +/- 0.146 gr/cm2 in cases with veiled clothing style while it was measured 0.8532 +/- 0.177 in cases with unveiled clothing style (P = 0.548, t = 0.457). Although a decrease in BMD values was observed in both regions with veiled clothing style, only the change in the lumbar spine BMD measurements was statistically significant. These findings suggest that the veiled clothing style may have an adverse effect on BMD by interfering with the sun exposure which is believed to have a key role in bone strength.

Three-dimensional ultrasound power Doppler assessment of the cervix: comparison between nulliparas and multiparas.

AIM: To assess the sonographic cervical characteristics between nulliparous and multiparous women. SUBJECT AND METHODS: Transvaginal three-dimensional ultrasound and power Doppler using the virtual organ computer-aided analysis (VOCAL) program were performed on 71 nulliparas and 59 multiparas at a mean gestational age of 25.3+/-7.9 weeks. We compared the cervical volume and power Doppler vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) between nulliparas and multiparas. RESULTS: The mean cervical volume and mean VI, VFI, FI measurements were not significantly different between multiparas and nulliparas. CONCLUSION: Our observations suggest that the morphological changes in the cervix of parous women are merely configurational without a change in cervical mass and vascularization. These configurational changes might result from the inevitable cervical stretching during labor and represent a healing process that does not involve a subsequent change in mass or vascularity.

Thoraco-omphalopagus conjoined twins detected at as early as 9 weeks of gestation: transvaginal two-dimensional ultrasound, color Doppler and fetoplacental Doppler velocity waveform findings.

Here we report a case of conjoined twins that were diagnosed antenatally by routine two-dimensional transvaginal ultrasound examination at as early as the 9th week of gestational age. The fetuses were of the thoraco-omphalopagus type and were sharing the liver, as confirmed by color Doppler. There was a reversed flow in the single ductus venosus of the twins. Umbilical arterial and venous blood flow waveform did not show any abnormality for this gestational age. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins in the first trimester by transvaginal two-dimensional ultrasound and color Doppler examination. Although conjoined twins were described at first trimester before, fetoplacental Doppler waveform findings at this gestational age have been described very rarely. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins and delineating the extent of organ sharing in the first trimester, and early diagnosis can help the parents with the option for pregnancy termination. The importance of expert early vaginal sonography and color Doppler findings is emphasized.

The effect of bilateral oophorectomy on bone mineral density.

The objective of this study is to investigate the effect of bilateral oophorectomy with total abdominal hysterectomy on bone loss, comparing the cases having surgery before and after the menopause. Bone mineral density (BMD) measurements were obtained from the lumbar spine and femoral neck of totally 127 cases. Out of 127, 105 had surgery before menopause and 22 cases were operated on postmenopausally. The results were compared with the USA normal values. The average age of surgical menopause (SM) cases was 48.45 years with a mean duration of menopause of 5.77 years. The average height and weight were 157.67 cm and 68.19 kg, respectively. The average age of cases having surgery after menopause (SAM) was 62.45 years with a mean duration of 5.59 years after the surgery (duration after menopause is 13.23 years). The average height and weight were 157.45 cm and 73.55 kg, respectively. The average of BMD measurements of lumbar spines L2-L4 was 1.04 gr/cm(2) (BMD = 85.65% and T score = -0.96) in the cases with SM. On the contrary, the average of the BMD measurements of lumbar spines L2-L4 was 1.05 gr/cm(2) (BMD = 101.14% and T score = 0.24) in the cases with SAM. The average of the BMD measurements of femoral neck was 0.85 gr/cm(2) (BMD = 91.39% and T score = -0.64) in the cases with SM. On the contrary, the average of the BMD measurements of femoral neck was 0.82 gr/cm(2) (BMD = 96.69% and T score = -0.31) in the cases with SAM. The bilateral oophorectomy as a surgical procedure is not a statistically significant factor for the acceleration of the bone loss. The main points are the age and the duration of menopause of the patient affecting the bone loss if the surgery is performed before menopause.

Effect of smoking on pregnancy-associated plasma protein A, free beta-human chorionic gonadotropin, and nuchal translucency in the first trimester of pregnancy.

Data were collected from 1275 pregnant Turkish women screened prospectively for chromosomal anomalies to determine whether first-trimester levels of maternal serum pregnancy-associated plasma protein A (PAPP-A) and free beta-human chorionic gonadotropin (beta-hCG) and the thickness of nuchal translucency are affected by smoking and other covariables. Only normal singleton pregnancies were included. After weight correction, comparisons were made between smokers and nonsmokers. Mean values of PAPP-A and beta-hCG were reduced in women who smoked 5 or more cigarettes a day compared with nonsmokers. The median beta-hCG level decreased significantly as gravidity and parity increased; no effect was noted on PAPP-A. Median PAPP-A and beta-hCG levels tended to increase, but not significantly in women who had had 2 or more miscarriages. Smoking alters maternal levels of serum analytes, with the magnitude of the impact related to the number of cigarettes smoked per day. This effect can be detected in the first trimester of pregnancy.

The efficacy of first-trimester PAPP-A and free beta hCG levels for predicting adverse pregnancy outcome.

OBJECTIVE: To determine whether first-trimester measurements of maternal serum PAPP-A and free beta hCG levels were associated with adverse pregnancy outcomes. STUDY DESIGN: First trimester maternal serum free beta hCG and PAPP-A were measured in 490 singleton pregnancies. Pregnancies were followed by the fetal-maternal unit, and predictive efficacy of these markers for small for gestational age (SGA) babies, gestational diabetes mellitus and hypertensive disorders were analyzed by cut-off values determined by using a ROC analysis, and also, by using the fifth percentile as the cut-off value. RESULTS: The sensitivities for PAPP-A in predicting pregnancies with a SGA baby and those complicated by a hypertensive disorder were 49% and 73%, respectively, when optimal cut-off values were used. Specificities were 76% and 65%, respectively. Serum free beta hCG had no predictive value for individual pregnancy outcomes. CONCLUSION: Efficacy of first trimester maternal serum markers in predicting adverse pregnancy outcome is low. Even after optimization of cut-off values, these markers do not appear to be clinically acceptable as an effective tool for screening for adverse pregnancy outcomes.

Intra- and interobserver agreement on cervical volume and flow indices during pregnancy using transvaginal 3-dimensional ultrasonography and Doppler angiography.

OBJECTIVES: To assess intra- and interobserver agreement in cervical volume and flow indices measurements. METHOD: We prospectively examined 126 patients by two seperate observers using transvaginal 3D gray-scale and power Doppler ultrasound. The two acquired volume datasets were analyzed using the VOCAL imaging program for assessing cervical volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI). Reproducibility of volume and vascularity measurement was assessed by calculating intraclass (intra-CC) and interclass (inter-CC) correlation coefficients (ICCs). RESULTS: Both intraobserver and interobserver cervical volume measurements were in perfect agreement with intra-CC values of 0.95, 0.96 for both examiners and with an inter-CC value of 0.95. Intraobserver agreement for VI, FI and VFI measurements were as good as the interobserver agreement for VI, and VFI measurements were adequate but less for FI measurements (inter-CC 0.67). Overall, volumetric data were more reliably acquirable than power Doppler measurements. CONCLUSIONS: 3D ultrasound gray-scale and power Doppler measurement of cervical volume and vascularization have acceptable intra- and interobserver variations and thus may be used in clinical research of cervical physiology and pathophysiology during pregnancy.

Predictive power of maternal serum and amniotic fluid CRP and PAPP-A concentrations at the time of genetic amniocentesis for the preterm delivery.

OBJECTIVE: To investigate whether maternal serum and amniotic fluid CRP and PAPP-A concentrations at the time of genetic amniocentesis are markers of preterm delivery. STUDY DESIGN: One hundred and forty-one pregnant women were included in this prospective study. Amniotic fluid and maternal serum CRP and PAPP-A concentrations were determined by using commercially available kits. Receiver-operating characteristic (ROC) analysis was performed to determine the efficacy of maternal serum and amniotic fluid CRP and PAPP-A levels in predicting women with preterm delivery. RESULTS: The prevalence of spontaneous preterm delivery before 37 weeks of gestation was 9.9%. ROC analysis revealed that amniotic fluid CRP level was the only parameter, which had a significant power in the prediction of preterm delivery. The optimum cut-off level was 0.65 mg/L. The sensitivity and specificity were 92.9% and 78.7%, respectively. CONCLUSION: The amniotic fluid CRP level has a high sensitivity and specificity in the prediction of preterm delivery and this may be helpful in predicting preterm delivery during genetic amniocentesis.

Primary malignant melanoma of the vagina: a case report and review of the current treatment options.

A case with primary malignant melanoma located in the posterior lower third of the vagina was encountered and treated by surgery, postoperative immunotherapy and chemotherapy. The tumor was close to the anal sphincter and posterior exenteration was done to achieve tumor-free surgical margins. The need for such radical treatment prompted us to review the literature and discuss our case with the rarest localization of the tumor in the vagina. We focused on the treatment options and the possible complication that may arise during the treatment of the primary malignant melanoma of the vagina. The need for radical surgery was discussed and the current treatment options were reviewed.

Antral follicle assessment after down-regulation may be a useful tool for predicting pregnancy loss in in vitro fertilization pregnancies.

Women with diminished ovarian reserve (OR) have a high rate of pregnancy loss. The relationship between hormonal OR tests and pregnancy loss has been studied previously, but, to our knowledge, that between the antral follicle count (AFC) and pregnancy loss has not. Therefore, we aimed to determine whether OR tests, including the AFC, can predict pregnancy loss in women achieving pregnancy by means of in vitro fertilization (IVF), and also to compare their predictive value. All women underwent a fresh cycle of intracytoplasmic sperm injection with a long protocol with mid-luteal start of the gonadotropin-releasing hormone analog, and antral follicles were counted on cycle day 3 following down-regulation. Pregnancy losses up to 12 gestational weeks (n=28) were compared with apparently healthy deliveries (n=34) in this retrospective analysis. Receiver operating characteristic analysis of consecutive pregnancies (n=71) was performed to analyze the optimum cut-off value for the significantly different OR tests. Women with a pregnancy loss had a lower AFC than those with healthy deliveries. Age and hormonal OR tests were comparable between groups. The optimum cut-off value for the AFC to predict pregnancy loss was 7.5. AFC may be a useful tool for predicting pregnancy loss in IVF pregnancies.

Screening for pre-eclampsia by using maternal serum inhibin A, activin A, human chorionic gonadotropin, unconjugated estriol, and alpha-fetoprotein levels and uterine artery Doppler in the second trimester of pregnancy.

AIMS: To analyse the predictive power of maternal serum inhibin A, activin A, human chorionic gonadotropin (hCG), unconjugated estriol (uE(3)), alpha-fetoprotein (AFP) levels and uterine artery Doppler in the second trimester of pregnancy in screening for pre-eclampsia. METHODS: Maternal serum inhibin A, activin A, hCG, uE(3), and AFP levels and uterine artery Doppler were determined in 178 healthy, pregnant women in the second trimester of pregnancy. Serum samples were collected between the 16th and 18th weeks of gestation, and Doppler investigation was performed between the 24th and 26th weeks of gestation. Receiver operating characteristic curves were created to analyse the predictive powers of the above parameters in screening for pre-eclampsia. Different combinations also were analysed. RESULTS: The rate of pre-eclampsia was 7.9% (14/178). Maternal serum inhibin A, activin A, hCG, AFP levels, the rate of presence of the prediastolic notch and uterine artery resistance index (RI) values in pre-eclamptic pregnancies were significantly higher than those in healthy pregnancies. Presence of the prediastolic notch, uterine artery RI, maternal serum activin A and inhibin A levels had high predictive efficacy, and each had a sensitivity between 70 and 93% and a specificity between 87% and 98%. The addition of inhibin A or activin A measurement to the Doppler velocimetry improved the specificity to 99-100%. CONCLUSIONS: Maternal serum inhibin A and activin A levels and uterine artery Doppler appear to be useful screening tests during the second trimester for pre-eclampsia. However, addition of these hormonal markers to Doppler velocimetry only slightly improves the predictive efficacy, which appears clinically insignificant.

Primary leiomyoma of the ovary co-existing with serous cystadenofibroma.

A 48-year-old woman with a 14 cm left ovarian mass had total abdominal hysterectomy and bilateral salpingo-oophorectomy. On cut section the tumor had a solid and a cystic component. There was a 2.5 cm nodule attached to the cyst wall. Sections taken from the solid component revealed a tumor composed of interlacing bundles of fusiform cells, resembling a leiomyoma. Smooth muscle actin positivity confirmed the diagnosis. Sections taken from the nodule in the cystic part revealed an adenofibroma. There was an SMA positive area in the cyst wall which we think is the possible origin of the leiomyoma. As far as we know, this is the first case of a co-existing leiomyoma and serous cystadenofibroma in the ovary, and we think it will broaden the histological spectrum of primary ovarian leiomyomas.

Differential diagnosis of smooth muscle tumors utilizing p53, pTEN and Ki-67 expression with estrogen and progesterone receptors.

BACKGROUND/AIM: To investigate the expression and value for diagnosis of the genes, p53 and pTEN, the protein, Ki-67, and the receptors, estrogen and progesterone, in differentiating smooth muscle tumors of the uterus. MATERIAL AND METHOD: Seventeen samples of leiomyosarcoma, 2 smooth muscle tumors with uncertain malignant potential (STUMP), 9 atypical myomas and 15 leiomyomas were stained immunohistochemically. The chi(2) test was used for the statistical analysis of the data. RESULTS: The malignant side of the spectrum was strongly stained for Ki-67 and p53 while uniformly decreasing toward the benign tumors. The results were found to be statistically significant (p < 0.0001). The staining for progesterone receptor was also statistically significant, but the tumors that were considered benign, such as leiomyoma and atypical myoma, were the ones strongly stained (p = 0.005). The expression of estrogen receptor was significant in these tumors, but the p value was very close to the cut-off value (p = 0.07). As the degree of differentiation of the tumor increased, the trend showed stronger staining for estrogen receptor. However, no difference was detected in the staining properties of the tumors for pTEN (p = 0.2457). CONCLUSION: The expression of Ki-67, p53 and progesterone receptors is promising in immunodifferentiation of smooth muscle tumors of the uterus with malignant potential.

Maternal serum, amniotic fluid and cord leptin levels at term: their correlations with fetal weight.

AIMS: To investigate the relationship between fetal weight and leptin levels in maternal serum, amniotic fluid and umbilical cord. METHODS: Forty pregnant women presenting for antenatal care at early weeks of gestation were enrolled for the study. Maternal and cord blood samples for leptin measurement were obtained at birth. Amniotic fluid samples were recovered by amniotomy performed during labor. Maternal body mass index and placental weight were also recorded. Leptin measurement was carried out using the ELISA method. Spearman's correlation test was used for comparison of non-parametric data. RESULTS: Leptin concentration in venous cord blood correlated significantly with birth weight and placental weight whereas maternal serum and amniotic fluid leptin levels did not show correlation with birth weight. There were no significant correlations between leptin levels in maternal serum, cord blood and amniotic fluid. CONCLUSION: We conclude that lack of correlation between leptin levels in mother, cord and amniotic fluid suggest that these compartments may be non-communicating separate units or have different mechanisms regulating leptin synthesis or degradation, and that leptin in maternal blood and amniotic fluid may not have a direct effect on fetal growth but rather a different role in pregnancy.

Apoptosis in the endometrium of postmenopausal women receiving tibolone.

BACKGROUND/AIM: Tibolone, a synthetic derivative of the 19-nortestosterone family, induces atrophy of the endometrium, especially via its progestogenic Delta(4) isomer. The aim of the study was to determine whether tibolone induces apoptosis in the endometrium of postmenopausal women. METHODS: Twenty healthy postmenopausal women (mean age +/- SD 52.4 +/- 4.21 years) who had amenorrhea for at least 1 year and who had no history of any systemic illness and estrogen replacement therapy were enrolled in the study. All patients were offered office endometrial samplings, and then tibolone was prescribed (2.5 mg/day p.o., once daily) to all patients. Repeat endometrial samples were obtained after completion of the 6-month course of tibolone therapy. All samples were immunohistochemically analyzed for the presence of apoptotic cells. RESULTS: There was no significant difference in the median proportion of apoptotic nuclei between the pre- and posttreatment samples (2 vs. 3%; p > 0.05). CONCLUSIONS: The results showed that tibolone did not affect the rate of apoptosis in the postmenopausal endometrium. Further studies are needed to clarify the role of apoptosis in overall effects of hormonal compounds on the postmenopausal endometrium.

Incidental carcinoid of appendix in cesarean section.

A case with carcinoid tumor of the appendix was encountered incidentally during an elective cesarean section. The tumor was discovered as a result of the routine exploration of the whole abdomen. The investigation for metastasis proved no evidence of spread and the patient was treated solely by surgery.