Retained Placenta Percreta with Acquired Uterine Arteriovenous Malformation-Case Report and Short Review of the Literature.

Placenta accreta spectrum disorder (PAS) has an increased frequency due to the high number of cesarean sections. The abnormal placentation associated with a retained placenta can cause persistent uterine bleeding, with ultrasound Doppler examination being the main choice to assess the uterine hemorrhage. An acquired uterine arteriovenous malformation (AVM) may occur because of uterine trauma, spontaneous abortion, dilation and curettage, endometrial carcinoma or gestational trophoblastic disease. The treatment for abnormal placentation associated with AVM can be conservative, represented by methotrexate therapy, arterial embolization, uterine curettage, hysteroscopic loop resection or radical, which takes into consideration total hysterectomy. Therapeutic management always considers the degree of placental invasion, the patient hemodynamic state and fertility preservation. Considering the aspects described, we present a case of retained placenta percreta associated with acquired uterine AVM, with imagistic and clinical features suggestive of a gestational trophoblastic disease, successfully treated by hysterectomy, along with a small review of the literature, as only a few publications have reported a similar association of diagnostics and therapy.

Presence of tumor cells in the vagina during surgical treatment could be the source of vaginal recurrence in patients with endometrial carcinoma - A pilot prospective study.

BACKGROUND: The commonest site of recurrence in endometrial cancer (EC) is the vagina, with a rate of 16%. The aim of this study was to determine if vaginal recurrences in EC patients could develop due to contamination of the vagina with glandular tumor cells dropping off on polypoid, large size EC or tumors involving the endocervix, through manipulation of the uterus during surgery. METHODS: This pilot prospective study included 10 consecutive patients with EC, surgically treated with hysterectomy and additional lymphadenectomy according to stage. In every case, 2 proximal vaginal smears were collected before and during the hysterectomy procedure. All smears underwent Papanicolaou staining and the presence of atypical glandular cells in the smears was correlated with clinico-pathological parameters. RESULTS: Residual tumor was identified on the surgical specimen in the 10 cases; the tumor characteristics were large size (median 6 cm), polypoid type (80%), infiltrating the cervix (70%), and infiltrating more than half of the myometrium (60%). The smears obtained from the vagina showed that five cases (50%) presented tumor cells of glandular type in all smears (before and during the surgery), while in 3 cases (30%) the smears were negative for tumor cells preoperatively, but positive in the perioperative smears. CONCLUSIONS: Our results suggest that the vagina is most often contaminated preoperatively due to bleeding; however, the vaginal wound may also be contaminated perioperatively. We propose a change in the surgical procedure, which is easy to perform and inexpensive compared to postsurgical vaginal radiotherapy.

Multiple versus unifocal breast cancer: clinicopathological and immunohistochemical differences.

Multiple breast cancer (MBC) is a controversial topic due to the lack of a consensus regarding its definition, classification issues and imprecise management recommendations in current reference guidelines. In four years, 756 patients with breast cancer (BC) were surgically treated in our Unit, 91 (12.03%) of them being pathologically diagnosed as MBCs. We present the results of our retrospective case-control study that performed a comparison between the clinicopathological characteristics and immunohistochemical (IHC) profiles of our MBC group versus a control group, represented by a sample of 184 cases randomly chosen from those with unifocal breast cancer (UBC). Starting from the premise of increased biological aggressivity of MBC, showed by several reports, we proposed to research the possible differences between these groups and to highlight their potential predictive and/or prognostic value. We found that MBC patients have a poorer prognosis than UBC ones - younger age at diagnosis [more cases less than 50 years old (p=0.03)], a lower frequency of T1 and a higher rate of T3 tumors [when using aggregate tumor size measuring method (p<0.001)], fewer node-negative (N0) cases (p=0.046) and a higher frequency of mucinous breast carcinoma (p=0.026). It worth mentioning that we obtained lower rates of poorly differentiated (G3) tumors (p=0.022) in the MBC group, this result being opposite to those found by other researchers. Our study also revealed a higher rate of human epidermal growth factor receptor 2 (HER2∕neu)-type cases in MBC group (p=0.022), these patients having the chance to benefit from treatment with monoclonal antibodies, with a better outcome than patients with triple-negative type. We registered significantly lower progesterone receptor (PR) positivity rates in patients with MBC, thus having a negative predictive value by showing a worse response to hormone-based therapies. Besides, we found heterogeneity of IHC features among tumor foci in MBC that may influence the therapeutic decisions. Our results sustain that MBC is biologically a more aggressive type of mammary neoplasia requiring a more particular therapeutic approach.

Mind the Gap Between Scientific Literature Recommendations and Effective Implementation. Is There Still a Role for Surgery in the Treatment of Locally Advanced Cervical Carcinoma?

According to evidence accumulated in the last years, many cancer centers recommend a treatment plan based solely on chemo-radiotherapy and exclude surgery from the treatment options in locally advanced cervical cancer (LACC). In Romania, surgery was at the forefront of therapeutic options. Nevertheless, current data shows that in fact, a large number of patients are still referred to surgery in various stages of diagnosis and treatment. It was noted that recommendations may differ, in spite of the wide dissemination of the literature data.Works published so far, discussing the role of surgery in LACC treatment shows a lack of consensus. A group of experts in oncology (SURCECAN research group - Surgery of Cervical Cancer) met for a session of the Romanian Surgical Society (Bucharest) on April 18, 2018. They found that LACC therapeutic strategy in Romania may differ somewhat from the European recommendations.On top of that, late enrolement to RT and low acces to specialized centers are the problem. Performing surgery not only allows the evaluation of the pathological response to chemo-radiotherapy, but also achieves a better local control. In conclusion, there is still a place for surgery within locally advanced cervical cancer treatment options. More trials need to be carried out in order to confirm the findings and establish high levels of confidence for each piece of information provided.

International radical trachelectomy assessment: IRTA study.

BACKGROUND: Radical trachelectomy is considered a viable option for fertility preservation in patients with low-risk, early-stage cervical cancer. Standard approaches include laparotomy or minimally invasive surgery when performing radical trachelectomy. PRIMARY OBJECTIVE: To compare disease-free survival between patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive (laparoscopic or robotic) radical trachelectomy. STUDY HYPOTHESIS: We hypothesize that minimally invasive radical trachelectomy has similar oncologic outcomes to those of the open approach. STUDY DESIGN: This is a collaborative, multi-institutional, international, retrospective study. Patients who underwent a radical trachelectomy and lymphadenectomy between January 1, 2005 and December 31, 2017 will be included. Institutional review board approval will be required. Each institution will be provided access to a study-specific REDCap (Research Electronic Data Capture) database maintained by MD Anderson Cancer Center and will be responsible for entering patient data. INCLUSION CRITERIA: Patients with squamous, adenocarcinoma, or adenosquamous cervical cancer FIGO (2009) stages IA2 and IB1 (≤2 cm) will be included. Surgery performed by the open approach or minimally invasive approach (laparoscopy or robotics). Tumor size ≤2 cm, by physical examination, ultrasound, MRI, CT, or positron emission tomography (at least one should confirm a tumor size ≤2 cm). Centers must contribute at least 15 cases of radical trachelectomy (open, minimally invasive, or both). EXCLUSION CRITERIA: Prior neoadjuvant chemotherapy or radiotherapy to the pelvis for cervical cancer at any time, prior lymphadenectomy, or pelvic retroperitoneal surgery, pregnant patients, aborted trachelectomy (intra-operative conversion to radical hysterectomy), or vaginal approach. PRIMARY ENDPOINT: The primary endpoint is disease-free survival measured as the time from surgery until recurrence or death due to disease. To evaluate the primary objective, we will compare disease-free survival among patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive radical trachelectomy. SAMPLE SIZE: An estimated 535 patients will be included; 256 open and 279 minimally invasive radical trachelectomy. Previous studies have shown that recurrence rates in the open group range from 3.8% to 7.6%. Assuming that the 4.5-year disease-free survival rate for patients who underwent open surgery is 95.0%, we have 80% power to detect a 0.44 HR using α level 0.10. This corresponds to an 89.0% disease-free survival rate at 4.5 years in the minimally invasive group.

Porocarcinoma: a rare cause of lateral cervical tumor.

Porocarcinoma is a rare tumor of the eccrine sweat glands that usually disseminates to the regional lymph nodes, but it can also develop distant metastasis. Case presentation: We report the case of a 67 year-old female patient who underwent wide surgical resection of a left cervical cutaneous tumor in a primary care center, for which the histology exam of the specimen was mixed basal cell and squamous cell carcinoma. She was referred to our hospital's oncology clinic and histologic re-evaluation changed the diagnosis to eccrine porocarcinoma (EPC). Computer-tomography (CT) revealed cervical lymphadenopathies for which the patient underwent 4 cycles of chemotherapy, without regression. She subsequently underwent a left upper anterior jugular lymphadenectomy (group IIa) with all nodes being negative and, three months later, she developed a unique adenopathy under the parotid gland that was excised and confirmed to be metastatic. Postoperative external radiotherapy was administered with a good outcome on CT scan. Nine months after her last surgery, the patient did not show any sign of recurrence or distant metastasis. Conclusion: EPC is a challenge, both diagnostically and therapeutically. In the absence of consensus regarding the indications and extent of lymphadenectomy and adjuvant therapy, patients with EPC should be referred to an experienced multidisciplinary team in a tertiary center.

Pelvic exenteration, a surgical treatment option for locally advanced, primary and recurrent neoplasia.

Pelvic exenteration (PE) is an extensive surgical procedure for locally advanced primary neoplasia (LAPN) or recurrent neoplasia (RN) that consists in the en bloc removal of the pelvic organs (rectum, internal genital organs and bladder) associated with pelvic lymph nodes. PE is classified into anterior, posterior and total, supra or infralevatorian approaches. Our aim was to evaluate the surgical procedure and the resection margins in correlation with postoperative complications and morbidity rates after PE in patients treated in a single surgical unit. The study group comprised patients diagnosed with different malignancies, surgically treated by using PE procedure, during 2012-2018. The cohort included 121 cases with LAPN (n=98, 80.99%) and RN (n=23, 19%), mostly female (n=114, 94.21%), with a mean age of 61.16 (33-85) years. LAPN had predominantly digestive (n=48, 49.98%) and gynecological (n=28, 28.57%) origins, while the majority of RN cases were cervical cancers (n=9, 39.13%). The univariate analysis showed that the gynecological origin of the tumor (p=0.02), urinary stoma (p=0.02) and posterior PE (PPE) (p=0.004) were significant prognostic factors for postoperative complications. After performing the multivariate analysis, only the gynecological origin (p=0.02) of the tumor and PPE (p=0.03) remained determining factors for postoperative complications. PE is a disabling surgical procedure associated with high postoperative mortality and morbidity, although it is often the only solution for advanced cases. The judicious selection of patients who can benefit from such extensive surgery is compulsory. Our study suggests that the gynecological origin of the tumor and PPE are key factors in postoperative complications.

Preliminary results of the first cervical cancer screening programme in the North Eastern region of Romania.

OBJECTIVE: Cervical cancer represents a major health problem in Romania. A national population-based cervical cancer screening programme was launched in 2012. The aims of the study were to assess the participation rate and to estimate the prevalence of epithelial cell abnormalities in the first four years of the programme in North Eastern Romania. METHODS: The participation rate, representing the proportion of eligible women screened in the programme, was evaluated for 2012-2016. The prevalence of cytological abnormalities was estimated by age group and calendar year. RESULTS: Of 107,968 Pap smears taken, 312 were unsatisfactory (0.3%). The number of smears decreased by year. The participation rate over the four years was 16.9%. Of the 107,656 satisfactory smears, 6.5% were positive for squamous and/or glandular lesion, among which 0.5% contained high-grade squamous intraepithelial or worse lesions. CONCLUSION: The participation rate in the first four years of the programme was low. The effectiveness of the screening programme should be improved by attendance monitoring of the target population, and follow-up of screen-positive women. Measures should be taken to raise coverage and assure quality at all steps of the screening chain. The data collected should include all screening tests from both opportunistic and organized settings.

Radical Trachelectomy Performed During Pregnancy: A Review of the Literature.

OBJECTIVE: Cervical cancer is one of the most frequent malignant diseases diagnosed during pregnancy. Abdominal or vaginal radical trachelectomies are fertility-preserving alternatives to radical hysterectomy for young women with early-stage cervical cancer that can be performed during ongoing pregnancy. METHODS: A literature review of articles on this subject was conducted through a Medline search for articles published in English or French. RESULTS: At this moment, 21 cervical cancer patients, including ours (4 stage IA2, 16 IB1, and 1 IB2) who underwent radical trachelectomy during pregnancy have been reported. Of these, 10 were performed by vaginal route and 11 were abdominal radical trachelectomies. CONCLUSIONS: Radical trachelectomy could be offered as an option for pregnant patients with early invasive cervical cancer. It may help women avoid the triple losses of a desired pregnancy, fertility, and motherhood.

Clinical Value of Hematological Biomarkers in Uterine Cervical Cancer.

Certain combinations of the hematological components, specifically, neutrophils and lymphocytes, named neutrophil to lymphocyte ratio (NLR) or multiplication of neutrophil and monocyte (MNM) have been shown to have prognostic value in a variety of cancers. MATERIAL AND METHODS: Retrospective study which included 133 patients with uterine cervical cancer with or without neoadjuvant therapy based on prognostic factors and correlations between NLR and MNM values, markers that were analyzed as continuous variables. This study aimed to establish the critical value of hematological markers. Results: NLR is significantly lower for preoperative stages I and II (p = 0.0004). There is a significant association between NLR and lymph node metastasis (p = 0.016), parametrial invasion (p = 0.035), lymphovascular space invasion (p = 0.0151) and tumor size (p = 0.0017). Correlational analysis showed that there is a significant association between MNM and lymph node metastasis (p = 0.020), parametrial invasion (p = 0.00010), lymphovascular space invasion materially affecting the value MNM (p = 0.0018), tumor size more than 4 cm (p = 0.0314). NLR and MNM were significantly lower in patients with complete response to neoadjuvant treatment. Discussion: The results of this study outlines the importance of hematological panel and parameters that can be easily used at no extra cost to establish further evolution of patients to treatment.

Abdominal radical trachelectomy: a Romanian series.

OBJECTIVE: Abdominal radical trachelectomy (ART) is one of the fertility-sparing procedures in women with early-stage cervical cancer. The published results of ART, in comparison with vaginal radical trachelectomy, so far are limited. MATERIALS AND METHODS: This retrospective study comprises all cases of female patients referred to ART with early-stage cervical cancer from 2 gynecologic oncology centers in Romania. RESULTS: A total of 29 women were referred for ART, but subsequently, fertility could not be preserved in 3 of them. Eleven women had stage IA2 disease (42.3%), 14 (53.8%) women had stage IB1 disease, and 1 (3.8%) woman had stage IB2 disease. Histologic subtypes were 15 (57.6%) squamous, 8 (30.7%) adenocarcinoma, and 3 (11.5%) adenosquamous. There were no major intraoperative complications in both hospitals. Early postoperative complications were mainly related to the type C parametrectomy-bladder dysfunction for more than 7 days (8 [30.7%] women) and prolonged constipation (6 [23.0%] women). Other complications consisted in symptomatic lymphocele in 2 (7.6%) patients, which were drained. Median follow-up time was 20 months (range, 4-43 months). Up to the present time, there has been 1 (3.8%) recurrence in our series. Most patients did not experience late postoperative complications. Three (11.5%) women are amenorrheic, and 1 (3.8%) woman developed a cervical stenosis. Of the 23 women who have normal menstruation and maintained their fertility, a total of 7 (30.4%) women have attempted pregnancy, and 3 (42.8%) of them achieved pregnancy spontaneously. These pregnancies ended in 2 first trimester miscarriages and 1 live birth at term by cesarean delivery. CONCLUSIONS: Our results demonstrate that ART preserves fertility and maintains excellent oncological outcomes with low complication rates.