Rapidly progressive primary undifferentiated ovarian carcinoma: presentation of a rare case.

Ovarian cancer is the second most common gynecologic malignancy and is one of the leading causes of death among women. The disease course and the accurate diagnosis are correlated with the early detection of the lesion. About 5% of ovarian cancers are poorly differentiated and difficult to be classified, and are referred to as undifferentiated carcinomas. They are usually large, solid with haemorrhage and necrosis, bilateral, and very difficult to be histologically classified. Generally, cases with undifferentiated components are very rare. The authors present a case of a young female patient with a rapidly progressive undifferentiated ovarian carcinoma and a final unfortunate clinical result.

Skin metastases of vulvar squamous cell carcinoma. Presentation of a rare case.

Skin metastases secondary to vulvar carcinoma is an infrequent clinical entity. The authors describe a case of squamous vulvar carcinoma, which presented with cutaneous involvement as a part of distant spread. After a radical vulvectomy, bilateral inguino-femoral lymphadenectomy, and adjuvant radiotherapy, the patient developed multiple cutaneous metastases in lower extremities. This case was unique in presentation, with skin metastases secondary from vulvar carcinoma, and indicated advance disease and poor prognosis.

Trocar metastases in laparoscopic approach for gynecologic malignancies. A short review of the literature.

INTRODUCTION: Compared to laparotomy, laparoscopy has many benefits for patients, such as shorter recovery and lower morbidity rates. Port site metastases after laparoscopic approach in the treatment of gynecologic malignancies are uncommon. The purpose of this review is to identify and summarize possible risk factors for port-site metastases in patients undergoing laparoscopic surgery in the ambit of gynecologic oncology. DISCUSSION: The precise incidence of port-site metastases is not well known because many patients are not followed-up during the whole postoperative period. Possible risk factors that can increase the risk of port-site metastases can be the presence of large masses in the abdomen, especially in the presence of concomitant ascites and in patients treated for ovarian carcinomas. Different theories have been postulated in order to explain the development of port site metastases during laparoscopy for oncological patients. CONCLUSIONS: Patient selection is an essential factor that can influence the incidence of port site metastases in gynecological patients. Robust data regarding port site metastases in gynecologic oncology are needed.

The role of mTOR signaling pathway in premalignant and malignant cervical lesions.

PURPOSE OF THE STUDY: Aberrant activation of the Akt/mTOR/pS6 signaling pathway has been identified in various types of cancer and is under investigation in cervical cancer. The purpose of this study was to assess the expression of the phosphorylated/activated forms of Akt (upstream molecule), 4E-BP1 and pS6 (downstream molecules) in biopsy samples of cervical low grade squamous intraepithelial lesions (LSIL), high grade squamous intraepithelial lesions (HSIL), and squamous cell carcinoma (Ca) compared to normal cervical epithelium. MATERIAL AND METHODS: The study included 38 cases diagnosed as LSIL, 31 cases as HSIL, 29 cases as Ca, and eight control cases from normal cervix. Immunohistochemistry was used to assess the expression of pAkt, p4E-BP1 and pS6. RESULTS: Statistical analysis revealed significant differences between HSIL and Ca groups compared to controls regarding intensity, positivity, and total scores for all three molecules (p < 0.001). A trend for higher expression with increasing grade of dysplasia was demonstrated. CONCLUSION: These results strongly support the view that the mTOR signaling pathway is involved in cervical carcinogenesis.

A rare case report of squamous-cell carcinoma arising from mature cystic teratoma of ovary.

The most frequent ovarian germ cell tumors are mature cystic teratomas (MCTs), composing 10-25% of all ovarian neoplasms. MCTs have the potential of undergoing malignant transformation, typically in postmenopausal women, with a frequency of 0.17-3%, with squamous cell carcinoma being the most common malignant tumor arising from MCT. We present the rare clinical entity of a squamous cell carcinoma arising from a mature cystic teratoma in a 56-year-old premenopausal woman as well as diagnostic and therapeutic route followed.

Fertility preservation in women with early stage cervical cancer. Review of the literature.

Within the last decades, the percentage of diagnosed cervical cancer in women of reproductive age has increased. The possibility of diagnosing small cervical tumors (< or = twocm) in childbearing age, can be explained due to the fact that many women, are aware of the benefits of Pap smear or colposcopy examination. Many demand a more conservative policy to handle such lesions in order to have an uneventful pregnancy in the near future.

Morbus Bourneville: a case report and review of the literature.

Tuberous sclerosis (TS) or tuberous sclerosis complex (TSC), also known as Bourneville disease or Bourneville-Pringle disease, is an autosomal dominant disorder classically characterized by the presence of hamartomatous growths in multiple organs. A combination of symptoms may include seizures, developmental delay, behavioral problems, skin abnormalities, and lung and kidney diseases. The authors present a case of a 18 year-old female patient with a history of TS, epileptic episodes, mental retardation, and papillary formations in multiple organs located at the abdominal, axillary, cervical, facial, and genital region.

Maternal and umbilical cord oxygen content and acid-base balance in relation to general, epidural or subarachnoid anesthesia for term elective cesarean section.

PURPOSE: To compare maternal and neonatal oxygenation and acid-base status after elective cesarean section (CS) under different anesthetic techniques. MATERIALS AND METHODS: Three hundred and eighty parturients undergoing elective cesarean section were randomly assigned to receive general (GA, n =140), epidural (EA, n = 117) or subarachnoid anesthesia (SA, n =123). Blood gases, oxygen content, and acid-base status parameters were measured in maternal artery and umbilical cord vessels. Neonatal Apgar scores were also recorded. RESULTS: Umbilical artery pH, HCO3-, and actual base excess (ABE) were significantly higher in the GA compared to SA group (p < 0.001, p < 0.05, andp < 0.05, respectively). Umbilical vein ABE was lower in the SA compared to GA and EA groups (p < 0.05). Oxygen content in maternal artery was higher in the GA and EA groups compared to the SA group (p < 0.05). Neonatal oxygen content in both cord vessels was higher in the GA group compared to EA and SA groups (p < 0.05). Umbilical venous-arterial difference of PO2, oxygen content, and Apgar scores did not differ significantly among groups. CONCLUSION: Neonatal oxygenation and acid-base status values were better preserved when GA was administered for elective CS compared to regional modalities. Apgar scores and neonatal outcomes were not affected by the anesthetic technique.

Effect of tamoxifen on postmenopausal endometrium.

PURPOSE: The objective of this study was to evaluate the effect oftamoxifen on the endometrium of45 postmenopausal women with breast cancer, as evidenced by hysteroscopic, ultrasound, histological methods, and by immunohistochemical investigation of the expression of Bcl-2 and Ki67. MATERIALS AND METHODS: Forty-five postmenopausal women with breast cancer (ER and/or PgR positive) undergoing tamoxifen therapy for six to 48 months, were selected from the files of the 2nd Department of Obstetrics and Gynecology, University of Athens Aretaieion Hospital, among a total of 120 patients treated from 2004-2009. RESULTS: The ultrasound findings during the follow-up period revealed 18 cases of thickened endometrium, 14 cases of suspected polyps, one case with accumulation of endometrial fluid, and 12 cases of heterogeneous endometrial echo texture. The patients had undergone hysteroscopy because of thickened endometrium (18/45 patients), postmenopausal bleeding (14/45 patients), and polyps (13/45 patients). The endometrial tissue samples were examined in the Pathology Department of Aretaieion Hospital and showed in 23 cases with adenomatous endometrial polyps, 15 cases with endometrial cystic atrophy, two cases with adenomatous hyperplasia, and five cases with mucosal endometrial adhesions. Immunohistochemical investigation of Bcl-2 and KJ67 expression was undertaken on paraffin blocks and showed elevated expression in the cases with endometrial polyps and hyperplasia, in contrast to atrophic endometria. CONCLUSION: Long-term tamoxifen therapy of postmenopausal women with breast cancer is associated with uterine pathology. Ultrasonography alone is useful in asymptomatic patients selecting cases with increased endometrial thickness for further investigation. Hysteroscopy is an accurate method for diagnosing endometrial disease because it provides a direct view of the uterine cavity, reveals focal lesions, and enables targeted biopsies to be performed at the same time. Pathological findings show elevated expression of Ki67 and Bcl-2 in hyperplastic endometria and adenomatous polyps, consistent with an elevated glandular cell proliferation due to tamoxifen effect.

Bioethical issues on the role of contemporary gynecologists concerning HPV vaccination.

UNLABELLED: Debate is heating up whether or not to require girls to be vaccinated against the human papillomavirus (HPV), a leading cause of cervical cancer (CC). Prolepsis against this plague is mainly focused on early detection with Pap test (screening) and recently with administrating HPV vaccines in youths. OBJECTIVE: To discuss the increased bioethical role of contemporary gynecologist in the young population, with the aim to contribute to the decrease of this malignancy. MATERIALS AND METHODS: The authors searched the web (data-warehouse: articles, forums, etc., and data-mining: sequence analysis and classification) for HPV vaccination and related bioethical issues. RESULTS: HPV vaccines have already caused debates on whether they must be mandatory and on whether they cause a pseudo-safeness mental state, making youths "forget" necessary annual Pap tests or even worse, urging them in promiscuity, resulting in an increased occurrence of CC. CONCLUSIONS: Greece, in order to appropriately apply the Constitutional Law 5 Section 5 (All persons have the right to the protection of their health...), needs to train contemporary gynecologists in adequate youth consultation and proper family approaches regarding HPV vaccination issues. Enhancing the gynecologist's role, vaccination's effectiveness (sensitivity and specificity) will be increased and on the other hand, a rule of social law will be established in the country.

Successful management of evisceration occurred after exploratory laparotomy for bilateral ovarian micropapillary serous borderline tumors.

Micropapillary serous borderline tumor of the ovary is characterized by a more frequent association with extraovarian, especially invasive, implants. The aim of this study was to report the clinicopathological findings of a rare case of micropapillary serous borderline tumor of the ovary since there are less than 100 similar cases in the published literature. Additionally, the successful management of evisceration that complicated the postoperative stay of the patient is analyzed. The incidence of this severe complication is estimated between 0.29-2.3%. There are four main causes: suture tearing through the fascia, knot failure, suture failure, and extrusion of abdominal contents between sutures placed too far apart. At least 50% of the cases are due to technical error with a potentially lethal result.

Clinicopathological study of 112 cases of benign, pre-invasive and invasive lesions of the vagina: a 15-year review.

OBJECTIVE: Benign vaginal lesions are mainly asymptomatic and often diagnosed during routine screening gynecological examinations. Additionally, vaginal intraepithelial lesions are asymptomatic and diagnosis is often confirmed after vaginal biopsy under colposcopic evaluation in cases of abnormal cytological Papanicolaou examination or synchronous cervical intraepithelial neoplasia. On the other hand, primary vaginal cancer is rare representing approximately 1-2% of all gynecological cancers. Metastatic invasion of the vagina is common especially in cases of advanced stage cervical cancer. The aim of this study was to examine the diagnostic approach, the management strategy, and the pathological findings in cases of benign, pre-invasive and invasive vaginal lesions that were diagnosed and treated in our Department. MATERIALS AND METHODS: This was a 15-year retrospective study. Cases of benign, pre-invasive, and invasive vaginal lesions diagnosed during the last fifteen years at Aretaieion Hospital of the University of Athens, were analyzed. RESULTS: During this study period 40 cases of vaginal cysts (35.7% of all vaginal lesions) were diagnosed. Surgical excision of the lesions was decided in all cases and histology showed that the most frequent cyst type was mucus-secreting Mullerian (30%). During the study period, 23 cases of vaginal intraepithelial neoplasia (VAIN, 20.5% of all vaginal lesions) were detected. In 43.5% of the cases, histological diagnosis revealed low grade VAIN, while the remaining cases were classified as high grade VAIN. Furthermore, 11 cases of primary vaginal cancer (9.8% of all vaginal lesions) were diagnosed. The vast majority of them (91%) were squamous cell carcinomas. Additionally, histology confirmed the diagnosis of metastatic invasion of the vaginal wall in 38 cases (34% of all vaginal lesions). In the majority of these cases (55.2%), primary cancer was located in the cervix. DISCUSSION: Benign, pre-invasive and invasive vaginal lesions are relatively uncommon and usually accompany lesions in other sites of the lower genital tract. Their diagnosis is based on gynecological or colposcopical examination. Treatment depends on the type of the lesion and the progression of the disease.

Female genital mutilation in Greece.

The number of migrants and refugees with a female genital mutilation (FGM) living in Greece is rising. This study explores the characteristics and psychosexual issues of women with FGM who were examined in the 2nd Department of Obstetrics and Gynecology, University of Athens Medical School, Greece during the year 2009. The women were asked to fill out an anonymous questionnaire asking for demographic data, obstetric history, current complaints, and psychosexual problems. The results are presented and discussed, as FGM is a new reality for Greece. Healthcare providers have to familiarize themselves with issues related to FGM and improve their skills in transcultural care, so as to manage and support women with FGM adequately.

Endometrial stromal sarcoma in a 29-year-old patient. Case report and review of the literature.

OBJECTIVE: Endometrial stromal sarcomas are rare tumors accounting for about 0.2% of all genital tract malignancies. They are considered to occur more often in premenopausal women. Endometrial stromal sarcomas are hormone sensitive tumors. A state of hyper-estrogenemia could act as a growth stimulus. Given the rarity of these tumors there are limited reports in the literature referring to the clinical management and final outcome of these cases. CASE: The patient, a 29-year-old woman, had a surgical history of myomectomy in another hospital three months before her referal to our department. The histological examination of the removed myoma showed an endometrial stromal sarcoma. Total abdominal hysterectomy, with bilateral salpingo-oophorectomy, omentectomy and elective pelvic lymphadenectomy were then performed as a second radical surgical approach. CONCLUSION: Endometrial stromal sarcomas are uncommon and their differential diagnosis from typical submucosal uterine myomas or benign endometrial polyps could be difficult. The hysteroscopic features of uterine sarcomas are often similar to those of endometrial polyps or submucosal myomas. The histological examination of the specimen is necessary to exclude malignancy and establish the final diagnosis. Total abdominal hysterectomy, bilateral salpingo-oopherectomy with pelvic lymphadenectomy is the optimal treatment in cases of endometrial stromal sarcomas.

Uterine tamponade balloon for the management of massive hemorrhage during cesarean section due to placenta previa/increta.

OBJECTIVE: Uterine tamponade with the Bakri catheter is effectively used as a treatment in postpartum hemorrhage and as a means to prevent fertility. CASE: We present a case of a 40-year-old pregnant woman who had a massive hemorrhage during cesarean section who was successfully treated with a tamponade balloon. Furthermore, we comment on a similar technique--Logothetopoulos pack--which was first developed and used in our department in the early years of the previous century. CONCLUSION: A conservative technique such as the Bakri catheter is an alternative intermediate step to control postpartum hemorrhage when pharmaceutical methods fail and before proceeding to obstetric hysterectomy.

The impact of HPV diagnosis on women's sexual and mental health: preliminary findings.

PURPOSE OF INVESTIGATION: The objective of the present study was to demonstrate the impact of HPV diagnosis on sexual function and mental health of Greek women. METHODS: The study population included 51 patients who proceeded to the gynecological outpatient clinic of "Aretaieion" Hospital, Athens, during 2008-2009. The participants were asked to complete a questionnaire regarding demographic characteristics, knowledge on HPV, gynecological and sexual history, as well as questions regarding their mental and sexual health after the diagnosis. RESULTS: Mean age of the participants was 36 years and mean age of their first Pap smear test was 24.4 years. Mean age of HPV diagnosis was 34 years and mean number of sexual partners was four. Regarding mental health, the majority experienced anxiety after the HPV diagnosis as well as fear regarding their health in the future. Nearly half of the women experienced guilt and anger and some of them distress, shame, diminution of self-esteem and stigmatization. Diminution in the level of sexual interest and desire and decrease in sexual intercourse frequency were quite often reported. CONCLUSION: Except for the important physical impact of HPV infection, its diagnosis seems to trigger several negative feelings and reduce sexual desire.

Clinicopathological characteristics of ovarian carcinomas associated with endometriosis.

INTRODUCTION: Substantial histopathology data provide evidence that endometriosis might be viewed as a precursor lesion of endometrioid and clear cell carcinoma of the ovary, via intermediary atypical borderline lesions. Also, genes involved in both endometriosis and epithelial ovarian cancer have been shown to play a role in the pathogenesis of endometriosis-associated ovarian carcinoma. MATERIAL AND METHODS: A retrospective study of 17 cases of ovarian carcinomas associated with endometriosis, diagnosed between 2000 and 2009, at Aretaieion Hospital of University of Athens, is presented. 10/17 cases in this study (58.8%) were clear cell carcinomas (CCC), 6/17 cases (35.3%) were endometrioid adenocarcinomas (EAC) and 1/17 cases (5.9%) was a serous carcinoma associated with ovarian endometriosis. Patients's age was 27-76 years (mean age 58 years). Typical ovarian endometriosis was documented in 8/17 (47%) of the tumors. In 9/17 cases, areas of fibrosis or cystic lesions infiltrated by iron-laden macrophages and endometrial-like stroma, consistent with endometriosis, were observed. CONCLUSION: In comparison with common epithelial ovarian cancers, CCC and EACs of the ovary were presented at earlier stages. Cytoreductive surgical treatment is critical in order to plan appropriate post-operative management.

Management of ASCUS findings in Papanicolaou smears. A retrospective study.

AIM: Atypical squamous cells of undetermined significance (ASCUS) are a cervical cytologic finding category suggestive but not definitive of squamous intraepithelial lesions. ASCUS remains an incompletely described entity and accounts for even 5%-10% of reported Papanicolaou (Pap) smears. The management of women with such cytologic findings remains controversial. The aim of this study was to evaluate the cytology laboratory findings with regards to ASCUS diagnosis, using cervical Pap smears, and colposcopic biopsies, as well as their management. MATERIALS AND METHODS: This is a retrospective study of patients with ASCUS Pap smears taken during the period January 2010 - December 2010 in the Second Department of Obstetrics and Gynecology, Aretaieion Hospital. RESULTS: During the study period, 657 Pap smears were examined at the Aretaieion Hospital; moreover, seven patients, whose Pap smears were cytologically diagnosed with ASCUS, were referred from other clinics, providing a total of 42 cases with a descriptive diagnosis of ASCUS for review. Of the 42 cases, eight were not studied because they were either lost in follow-up or they did not have available data. The remaining 34/42 patients were evaluated by colposcopic examination and directed biopsies where necessary. The ratio of ASCUS to low-grade squamous intraepithelial lesion (LGSIL), high-grade squamous cell intraepithelial lesion (HGSIL) or squamous cell carcinoma (SCC) was 5/34, 1/34, and 0/34, respectively. In the 34 ASCUS cases evaluated by colposcopy, the age distribution varied from 22 to 54 years. Eight of 34 cases did not have a child, 7/34 were primigravida, 18/34 were secondi-gravida, and 1/34 had four children. Four out of 34 cases were postmenopausal, 3/34 referred no history of abnormal bleeding, 21/34 were smokers, 6/34 used oral contraceptives, 2/34 used intrauterine devices, 1/34 took replacement of hormones, 4/34 had prior abnormal Pap smears human papillomavirus (HPV), or 1/34 had previous cancer (breast cancer). Colposcopy was inconclusive in 4/34 patients, while 8/34 cases were negative for Schiller and acetic acid tests and also had normal colposcopy. Infectious organisms were found in 8/34 patients with ASCUS, including actinomyces (1/8), trichomonas (5/8), and candida albicans (2/8). Histologic tests revealed 16/34 koilocytosis cases, 5/34 LGSIL, 1/34 HGSIL, and 0/34 SCC. CONCLUSION: The dilemma in the management of patients with an ASCUS diagnosis still exists as a significant problem for clinicians.

A rare ovarian Leydig cell tumor (hilar type) causing virilization in a postmenopausal woman.

All patients with virilization signs, increased levels of androgen hormones and rapidly progressive hirsutism should be evaluated for an androgen-producing tumor. The ovarian origin of virilization can be suspected by the presence of elevated levels of circulating androgens, with normal levels of cortisol metabolites and a negative dexamethasone suppression test. A case report of a 50-year-old postmenopausal patient with rapidly progressive hirsutism is presented. After an extensive preoperative investigation a right oophorectomy was performed and a Leydig-hilus cell tumor was diagnosed.

The role of oral contraception use in the occurrence of breast cancer. A retrospective study of 405 patients.

UNLABELLED: The investigation of potential predisposing factors of breast cancer, a disease accounting for almost one-third of malignancies in women, is necessary in order to reduce the incidence. MATERIALS AND METHOD: We interviewed 405 female patients who had been diagnosed with breast cancer and who also reported having used oral contraceptive pills before. They were categorized into two groups (group A < 7 years OC use and group B > 7 years OC use). RESULTS: Statistical analysis revealed a small (p < 0.02) but significant increased risk of the disease to BRCA mutation carriers, as well as to the women with a significant medical or family history of breast, ovarian or colon cancer who had also previously used oral contraceptive pills for more than seven years. DISCUSSION: Breast cancer seems to be positively dependent on prolonged oral contraceptive use. CONCLUSION: More research is needed to establish the hypothesis that the human genome is vulnerable to oral contraceptives.