Nerve sparing radical hysterectomy in early stage cervical cancer. Latest developments and review of the literature.

BACKGROUND: Cervical cancer is the second most common malignancy of the female genital tract worldwide. Radical hysterectomy with pelvic lymphadenectomy exemplifies the treatment of choice for early stage disease, whereas even if it is performed by gynaecologist-oncologist, still has the drawback of significant postoperative morbidity, especially for urinary bladder function. Nerve-sparing radical hysterectomy (NSRH) is a technique in which the neural part of the cardinal ligament which encloses the inferior hypogastric plexus, as well as the bladder branch (distal part of the plexus), remains intact. By this way, the bladder's innervation is safe and its functional recovery is more rapid. There is sufficient data to support the feasibility of the technique via laparotomy and laparoscopy, as well as the effectiveness related to the postoperative bladder dysfunction compared to conventional radical hysterectomy. On the other hand, the evidence related to survival outcomes is weak and derives from non-randomized trials. However, the low rate of local relapses after NSRH in early stage disease (IA2-IB1) with tumor diameter less than two cm makes the procedure suitable for this group of patients. CONCLUSION: According to the current evidence NSRH seems to be a suitable technique for gynaecologist-oncologist familiar with the method in early stage cervical cancer. It is a technique which improves significantly postoperative bladder recovery and the patients' quality of life (QoL), without compromising the oncological standard.

Uterine angioleiomyoma causing severe abnormal uterine bleeding.

BACKGROUND: Angioleiomyoma or angiomyoma or vascular leiomyoma is an unusual benign mesenchymal neoplasm. The authors present a rare case of large uterine angioleiomyoma causing severe abnormal uterine bleeding. CASE: The patient, a 53-year-old, gravida 2, para 2, premenopausal Greek woman presented with a complaint of severe abnormal uterine bleeding. On gynecologic examination there was a palpable pelvic mass. Preoperative computer tomography (CT) of the abdomen and pelvis revealed an intra-abdominal mass 25 x 15 cm with abnormally increased vascularization. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and elective pelvic lymph node dissection. Histopathology revealed uterine angioleiomyoma. Follow up 84 months after initial surgery showed no evidence of recurrence. CONCLUSION: Despite the type of surgery, patients with uterine angioleiomyoma have very low risk of recurrence and excellent prognosis.

The role of mini laparotomy in patients with uterine myomas.

AIM: The aim of this study was to evaluate the therapeutic effectiveness of myomectomy by mini laparotomy in patients with subserosal and/or intramural uterine myomas. MATERIALS AND METHODS: Between January 2002 and December 2008, 83 women with symptomatic uterine myomas were referred to the Second Department of Gynecology of St. Savvas Anticancer--Oncologic Hospital of Athens. The study included women with subserosal and/or intramural uterine myomas with a maximum diameter of ten cm. All patients underwent myomectomy by mini laparotomy. RESULTS: The median age of the patients was 36.8 years (range 19-43). The median number of the removed uterine myomas was 3.1 (range 1-12) and the median operative time was 98 minutes (range 47-170). All patients were mobilized within the first 24 hours and the median time of postoperative ileus was 1.6 days (range 1-3). The median hospital stay was 44 hours (range 30-120). There were no serious intraoperative or early postoperative complications. Conversion to laparotomy was performed only in four cases (4.82%), but none of the patients underwent emergency hysterectomy. During a mean follow up of 38 months, no recurrences of uterine myomas in the study population were observed. CONCLUSION: Mini laparotomic myomectomy is a safe and effective minimally invasive method alternative to laparoscopic myomectomy for patients with subserosal and/or intramural uterine myomas.

Laparoscopic myomectomy of a giant myoma.

We present the case of an infertile woman with a giant myoma which was laparoscopically removed. A 34-year-old patient was referred to our department with a large abdominal mass. Ultrasound revealed an 18 cm uterine myoma. Diagnostic laparoscopy showed a giant uterine myoma and with the help of a bent angle camera we started myoma enucleation. The myoma was totally enucleated and removed without disturbing the endometrial cavity. The uterine defect was closed with an absorbable suture in two layers. The myoma was removed using a PK (Gyrus) morcelator, without tissue or blood spillage in the abdomen. The operation time was 165 minutes and the myoma's weight was 1,200 g. The patient recovered uneventfully. Laparoscopic myomectomy can be an option even for giant myomas, with the condition of an expert surgeon and appropriate surgical instruments.

Uterine malignant mixed Müllerian tumor after adjuvant tamoxifen treatment for breast cancer.

BACKGROUND: Uterine malignant mixed Müllerian tumor (MMMT), also known as carcinosarcoma, is a biphasic tumor of the female genital tract and demonstrates both malignant epithelial (carcinoma) and mesenchymal (sarcoma) components. The authors present two cases of uterine MMMT after adjuvant tamoxifen (TAM) treatment for breast cancer and a review of the current literature. CASES: The patients presented with a complaint of abnormal uterine bleeding. They both had a history of breast cancer Stage IIB previously treated with modified radical mastectomy, at 51 and 78 months, respectively. They also had history of tamoxifen treatment 20 mg daily for seven and 73 months respectively. They underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy. Histopathology revealed a uterine MMMT. Postoperatively, they received adjuvant chemotherapy and radiotherapy. One of the patients died 26 months after initial surgery due to uterine MMMT. CONCLUSION: Uterine MMMT is a rare, highly-aggressive, and rapidly-progressing tumor associated with a poor prognosis. Postmenopausal patients, with prolonged adjuvant TAM treatment for breast cancer, are at increased risk for the development of uterine MMMT.

Laparoscopic para-aortic and pelvic lymphadenectomy and radical hysterectomy in a patient with cervical cancer, six months after primary chemoradiation.

Treatment of Stage IB-IIA cervical carcinoma is controversial. The choice to perform surgery or chemoradiation depends on the FIGO Stage, which does not include evaluation of lymph node involvement, although the prognosis of the patients depends on this evaluation. There is no method however, to safely evaluate preoperative lymph nodes metastasis, as both magnetic resonance imaging (MRI) and computed tomography (CT) have poor sensitivity and high specificity. As a result, inaccurate preoperative lymph node assessment can lead to suboptimal treatment. The authors report the case of a 42-year-old patient with cervical cancer Stage IB2, who was primary treated with chemoradiation. Although at the time of diagnosis no lymph node metastasis was detected, six months after treatment, an enlarged five-cm lymph node was found in the area of left iliac vein. The patient underwent laparoscopic pelvic and para-aortic lymphadenectomy and nerve sparing radical hysterectomy. Pathologic examination revealed one positive lymph node out of the 41 removed and no cancer cells in the uteral structures. There are cases of cervical cancer in which chemoradiation seems to be insufficient. Laparoscopic nerve-sparing radical hysterectomy can be the treatment in patients with lymph node metastasis after primary chemoradiation. It offers oncological safety combining the advantages of laparoscopy and the nerve-sparing technique. Furthermore, adjuvant chemotherapy or radiation can be initiated immediately, offering the best therapeutical choice in the authors' opinion.

Endometrioid ovarian cancer arising from an endometriotic cyst in a young patient.

OBJECTIVE: To present a case of a young woman with ovarian endometrioid adenocarcinoma arising from an endometriotic cyst and review of the literature. CASE REPORT: A 33-year-old woman, gravid 2, para 2 was admitted to our department with a 5 cm adnexal mass. Diagnostic laparoscopy was performed and pathological examination demonstrated an endometriotic cyst with an area of an ovarian endometrioid adenocarcinoma well differentiated, with no capsular invasion. One month after the operation the patient underwent MRI which revealed a 6 cm mass in the Douglas pouch. The multidisciplinary oncology council decided on exploratory laparotomy, which revealed no pathology. After that the multidisciplinary oncology council decided on adjuvant chemotherapy and the patient received four cycles of carboplatin/taxol. CONCLUSION: It should always be considered that even when there are no risk factors for malignancy occurrence, a high index of suspicion is necessary and will help to prevent delay in the diagnosis of this rare neoplasm.

Primary ovarian leiomyosarcoma.

BACKGROUND: Primary ovarian leiomyosarcoma is an extremely rare subtype of ovarian sarcomas. It most commonly occurs in postmenopausal women and has unfavorable prognosis. CASE: The patient, a 58-year-old postmenopausal woman, presented with a complaint of abdominal pain. Preoperative examination revealed an intraabdominal mass 25 x 17 x 14 cm in the right adnexa. She underwent bilateral salpingo-oophorectomy, total omentectomy, appendectomy and bilateral pelvic lymphadenectomy. The histopathology revealed leiomyosarcoma of the right ovary Stage Ia. She did not receive any postoperative adjuvant therapy. Follow-up 21 months after initial surgery, showed no evidence of recurrence. CONCLUSION: Additional studies are needed to understand more about the nature, clinical behavior and treatment of this very rare tumor.

Synchronous squamous cell carcinoma of the endometrium and endometrioid adenocarcinoma of the ovary.

BACKGROUND: Synchronous primary endometrial and ovarian cancers are relatively uncommon in general population. The etiology and pathogenesis of this phenomenon remains unclear. The authors' aim was to present a case of synchronous squamous cell carcinoma of the endometrium and endometrioid adenocarcinoma of the ovary and review current literature. CASE: The patient, a 64-year-old, nulliparous postmenopausal Greek woman presented with a complaint of abdominal pain and abnormal uterine bleeding. Preoperative computer tomography (CT) of the abdomen and pelvis, and abdominal ultrasound (U/S) revealed an intra-abdominal three cm mass with solid components between the left ovary and small bowel. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH+BS), total omentectomy, pelvic and para-aortic lymph node dissection, and removal of the implant at the serosa of small bowel. Histopathology revealed Stage IA endometrial cancer squamous type and Stage IIIC ovarian cancer of endometrioid-type. Postoperatively the patient underwent adjuvant chemotherapy and radiotherapy. Follow-up of 22 months after initial surgery revealed no evidence of recurrence. CONCLUSION: The reason for better median overall survival of patients with synchronous primary endometrial and ovarian cancers is not intuitively obvious. Perhaps favourable clinical outcome may be related with the detection of patients at early stage and low-grade disease with an indolent growth rate.

Loop electrosurgical excision procedure in Greek patients with vaginal intraepithelial neoplasia and history of cervical cancer.

OBJECTIVE: The aim of our study was to evaluate the therapeutic effectiveness of loop electrosurgical excision procedure (LEEP) in Greek patients with vaginal intraepithelial neoplasia (VAIN) and history of cervical cancer. MATERIALS AND METHODS: Between January 2002 and January 2009, eight women with histologically confirmed VAIN and history of cervical cancer were included in our study. For the LEEP procedure we used a high frequency Electrosurgery Unit with at least 80 W output. RESULTS: Complete response rate, at 12 months of follow-up, was 75%. Recurrence rate, at 12 months of follow-up, was 25%. Complete response rate, at 24 months of follow up, was 62.5%. Recurrence rate, at 24 months of follow up, was 37.5%. CONCLUSION: LEEP may constitute a valuable excisional method for the treatment of VAIN in cases with a history of cervical cancer. It provides an interpretable specimen of the whole lesion within a few minutes. It needs a short period of training and has low cost.

Proliferative Brenner tumor of the ovary. clinicopathological study of two cases and review of the literature.

BACKGROUND: Ovarian Brenner tumors are rare epithelial tumors that account for 1%-2% of all ovarian neoplasms. They can be subdivided into benign, borderline or proliferative, and malignant neoplasms. In the vast majority of cases, these lesions are benign. Tumors of borderline malignancy are less frequent and only about 1% of Brenner tumors are malignant. We present two cases of Brenner tumors with borderline malignancy which were treated in our Department together with a review of the literature. CASES: A 50-year-old, gravida 1, para 1, patient was admitted for abnormal vaginal bleeding. Clinical examination, abdominal ultrasound (US), and computed tomography (CT) revealed a cystic multilobulated tumor of the right ovary with solid elements measuring 20 x 19 x 15 cm in diameter. In the other case a 70-year-old, gravida 2, para 2, patient presented with severe urinary difficulties. Palpation revealed a mobile abdominopelvic tumor 10 x 15 in diameter. US and CT exhibited a cystic tumor with multiple solid elements and calcifications of the left ovary. Both patients underwent exploratory laparotomy. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy were performed in both cases, while pelvic lymphadenectomy was decided only in the second case. Histologically, in both cases the diagnosis confirmed borderline Brenner tumor. CONCLUSION: Although Brenner tumors are rare and the majority of them are benign, the correct histological diagnosis at frozen section with identification of the small proportion of malignant tumors, allows the extent of the operation to be adapted if needed.

Angiokeratoma of the vulva.

Angiokeratoma of the vulva is relatively uncommon in the general population. We present two cases of angiokeratoma of the vulva and review the literature. The two patients presented with the complaint of vulvar pruritus. They underwent wide local excision of the lesions. Histopathology revealed angiokeratoma of the vulva. The women remain well with no evidence of recurrence 48 and 32 months after initial surgery. Although it is a rare disease, angiokeratoma of the vulva should be included in the differential diagnosis of a vulvar tumor.

Primary ovarian non-Hodgkin's lymphoma.

BACKGROUND: Primary ovarian non Hodgkin's lymphoma (PONHL) is a very rare disease. We present a case of PONHL and review the literature. CASE: The patient, a 24-year-old nulliparous Greek woman, presented with the complaint of abdominal pain. She underwent left salpingo-oophorectomy, multiple biopsies from the right ovary, total omentectomy, pelvic and paraortic lymphadenectomy, appendectomy and curettage. The histopathology revealed diffuse large B-cell non-Hodgkin's lymphoma of the left ovary. She underwent postoperative chemotherapy. She remains well without evidence of disease, 15 months after initial surgery. CONCLUSION: The use of chemotherapy is based on the principle that PONHL must be considered a localized manifestation of systemic disease. Patients with PONHL have a similar outcome compared to patients with other NHL.

Fallopian tube primary cancer: report of five cases and review of the literature.

OBJECTIVE: The aim of this retrospective study was to analyze the clinical characteristics, management and prognosis of five patients with fallopian tube primary cancer (FTPC) who were diagnosed and treated in our departments. A review of the current literature is also presented. MATERIALS AND METHODS: Between January 2000 and August 2009, five cases with histologically confirmed FTPC were diagnosed in our departments and were then evaluated retrospectively. All patients underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy. RESULTS: We had two patients in Stage IA (40%), two patients in Stage IC (40%) and one patient in Stage IIIA (20%). All patients received adjuvant chemotherapy with platinum-based combinations and two of them received additional radiotherapy. CONCLUSION: FTPC, compared with ovarian primary cancer (OPC), is more likely to present at an early stage and have an overall more favourable outcome. More extensive clinical research must be performed to have definite aetiologic, diagnostic and management modalities.

Vaginal primary malignant melanoma: report of four cases and review of the literature.

OBJECTIVE: The aim of this retrospective study was to analyse the clinical characteristics, management and prognosis of four patients with vaginal primary malignant melanoma (VPMM) who were diagnosed and treated in our departments together with a review of the current literature. MATERIALS AND METHODS: Between January 1997 and September 2009, four cases with histologically confirmed VPMM were evaluated retrospectively. All patients underwent wide local excision. RESULTS: One patient was in Stage I (25%), two patients in Stage II (50%) and one patient in Stage IV (25%). Among them, one patient received additional radiotherapy and three patients received additional immunotherapy with interferon. CONCLUSION: The prognosis of VPMM is very poor, despite the treatment modality, because most cases are diagnosed at late stage.

Loop electrosurgical excision procedure in Greek patients with vaginal intraepithelial neoplasia.

OBJECTIVE: The aim of our study was to evaluate the therapeutic effectiveness of the loop electrosurgical excision procedure (LEEP) in Greek patients with vaginal intraepithelial neoplasia (VAIN). MATERIALS AND METHODS: Between January 2002 and January 2009, 23 women with histologically confirmed VAIN were included in our study. For the LEEP procedure we used a high frequency electrosurgery unit with at least 80 W output. RESULTS: Complete response rate at 12 months of follow-up was 86.96%. Recurrence rate at 12 months of follow-up was 13.04%. Complete response rate at 24 months of follow-up was 75%. Recurrence rate at 24 months of follow-up was 25%. CONCLUSION: LEEP may constitute a valuable excisional method for the treatment of VAIN. It provides an interpretable specimen of the whole lesion within a few minutes. It needs a short period of training and has low cost.

Synchronous primary endometrial and fallopian tube cancers.

BACKGROUND: Synchronous primary cancers are relatively uncommon in the general population. We present a case of synchronous primary endometrial and fallopian tube cancers and review the literature. CASE: The patient, a 54-year-old, gravida 2, para 2 postmenopausal Greek woman presented with a complaint of abnormal vaginal bleeding. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy. The histopathology revealed synchronous primary cancers of the endometrium and right fallopian tube. The patient underwent postoperative chemotherapy and postoperative radiotherapy. She remains well without evidence of disease, 65 months after initial surgery. CONCLUSION: The reason for the better median overall survival of patients with synchronous primary endometrial and fallopian tube cancers is not intuitively obvious. Perhaps it is due to the detection of patients at earlier clinical stage and lower grade disease state.

Loop electrosurgical excision procedure in Greek patients with vulvar intraepithelial neoplasia.

OBJECTIVE: The aim of our study was to evaluate the therapeutic effectiveness of loop electrosurgical excision procedure (LEEP) in Greek patients with vulvar intraepithelial neoplasia (VIN). MATERIALS AND METHODS: Between January 2002 and January 2009, 55 women with histologically confirmed VIN usual type were included in our study. For the LEEP procedure we used a high frequency electrosurgical unit with at least 80 W output. The tissue was removed to the second surgical plane. Statistical analyses were performed using the SPSS-13 for Windows. RESULTS: Complete response rate at 12-month follow-up was 100%. Complete response rate at 48 months of follow-up was 80%. Recurrence rate at 48 months of follow-up was 20%. CONCLUSION: LEEP may constitute a valuable excisional method for the treatment of VIN. It provides an interpretable specimen of the whole lesion within a few minutes. It needs a short period of training and has low cost.