Distribution of human papillomavirus types in Turkish women.

PURPOSE OF INVESTIGATION: Since oncogenic types of human papillomavirus (HPV) are associated with a higher risk of cervical cancer and certain types can be controlled by a vaccine, a study has been performed to determine the HPV genotype distribution among Turkish women. METHODS: The study included patients with abnormal cytology or in the follow-up for cervical intraepithelial neoplasia between 2002 and 2009 at Hacettepe University Hospital. The results of 1797 consecutive cervical samples were analyzed retrospectively. INNO-LiPA HPV genotyping, HPV-Typing and Seeplex HPV 18-plex genotyping tests were used to determine the types of HPV. RESULTS: HPV was detected in 404 (22.4%) of 1797 samples studied. HPV DNA was identified in 194 cases by using HPV-Typing test but the specific genotype was not available. The most frequent genotype was HPV 16 which was observed in 103 cases (49.0%). CONCLUSION: HPV 16 was the most common genotype observed among Turkish women with abnormal cytology. It suggests that HPV vaccination may be useful for prevention of cervical cancer in this population.

Preoperative serum leptin levels in patients with endometrial cancer and its correlation with prognostic variables.

PURPOSE OF INVESTIGATION: Since leptin is believed to be a key player in carcinogenesis, a study has been designed to investigate the relationship between leptin levels and endometrial cancer. METHODS: A study including 30 patients with endometrial cancer and 30 healthy controls was carried out between November 2008 and July 2009 in Hacettepe University Hospital. All patients with endometrial cancer underwent a complete surgical staging procedure including lymphadenectomy. Preoperative leptin levels of endometrial cancer patients and healthy controls were compared. The relationships between leptin levels and stage, grade, histological type and lymph node status of endometrial cancer cases were evaluated. RESULTS: The mean serum leptin levels were 16.9 ng/ml among endometrial cancer cases and 19.0 ng/ml among controls (p = 0.32). Of endometrial cancer cases, the mean leptin level was found to be 15.8 ng/ml for Stage I and 18.5 ng/ml for Stage II-IV disease (p = 0.34). The figure was 17.7 ng/ml for endometrioid and 13.2 ng/ml for non-endometrioid type of tumor (p = 0.24). The mean leptin levels of 16.3 ng/ml for grade 1 and 19.9 ng/ml for grade 2-3 tumors were observed (p = 0.07). The cases with positive and negative lymph nodes had leptin levels of 20.2 ng/ml and 16.1 ng/ml, respectively (p = 0.30). CONCLUSIONS: Serum leptin levels in endometrial cancer patients were similar to healthy controls. Leptin did not show any significant correlation with stage, grade, histological type and node metastases in endometrial cancer.

Non-Hodgkin's lymphoma complicating pregnancy: a case report.

A 40-year-old, gravida 3, para 2 woman was initially referred to our department at 31 weeks' gestation complaining of fever, night sweats, malaise in association with jaundice and pancytopenia. Cesarean section with excisional iliac lymph node biopsy was carried out following a period of expectant management. An 1,840 g healthy male infant with an Apgar score of 9 at 34 weeks of gestation was delivered. Histologic examination of the excised lymph node revealed non-Hodgkin's lymphoma (Histiocyte and T cell predominant B cell lymphoma). The patient was evaluated to have Stage II B disease. A chemotherapy regimen of CHOP/Rituximab was instituted with successful maternal-fetal prognosis.

Clinical results of a split sample liquid-based cytology (ThinPrep) study of 4,322 patients in a Turkish institution.

PURPOSE: A prospective study was carried out to compare the efficacy of liquid-based cytology (ThinPrep) with the conventional Pap smear using a split-sample design in a Turkish university hospital outpatient gynecology clinic. METHODS: 4,322 consecutive patients were recruited for the study between 2002 and 2003. All the patients underwent conventional Pap tests followed by a ThinPrep test for screening of cervical cancer. The results were evaluated in terms of the Bethesda III classification. All the patients with abnormal tests underwent colposcopy and directed biopsy. RESULTS: While 2.3% of the specimens were unsatisfactory for evaluation in the conventional Pap test group, this rate was 1.7% for the ThinPrep group. Epithelial cell abnormalities were observed in 42 (1.0%) patients in the conventional Pap test group and in 36 (0.8%) patients in the ThinPrep group. ASCUS was observed in 26 patients in the conventional Pap test group whereas the ThinPrep group had 20 cases of ASCUS as the leading cause of abnormal cytology. Biopsy of these cases revealed CIN 1 in two CIN 2-3 in three and cervical/endometrial adenocarcinoma in three patients. The ThinPrep application led to diagnoses of one additional case of CIN 2-3 and one case of adenocarcinoma among the negative or unsatisfactory for evaluation categories of the conventional Pap test group. CONCLUSION: Despite an adverse bias introduced by the split-sample study design, application of ThinPrep showed an improved rate of specimen adequacy and increased sensitivity for more significant cervical precursor lesions over the conventional Pap test.

An incidentally diagnosed epithelioid trophoblastic tumor in hysterectomy.

Epithelioid trophoblastic tumor is a rare non-molar gestational trophoblastic disease. A 40-year-old multiparous woman was incidentally diagnosed with epithelioid trophoblastic tumor after hysterectomy. Hysterectomy specimen revealed multiple small, tan to yellow nodules measuring 0.3-0.8 cm just below the endometrium. In the microscopic examination uniform neoplastic cells with varying cellularity were accompanied by necrotic zones and eosinophilic hyaline material. Immunohistochemically neoplastic cells were diffusely stained with CK 7, inhibin-alpha, p63, hPL, and CD146. There was no staining with beta-HCG, SMA, PLAP, or h-caldesmon. Ki-67 proliferative index was approximately 10% and cyclin E was stained in approximately 10% of the neoplastic cells. Although immunohistochemical studies are helpful in classifying gestational trophoblastic lesions, borderline values can cause diagnostic confusion between neoplastic and reactive lesions, particularly in inadequate endometrial biopsies.

Management of gestational trophoblastic diseases: subsequent pregnancy experience.

Patients with gestational trophoblastic disease (GTD) can usually achieve complete sustained remission while retaining their fertility even in the presence of wide-spread metastasis. Following complete and partial mole, our patients had 1,239 and 205 later pregnancies, respectively, which resulted in 68.6% and 74.1% term live births, respectively. Patients with either type of hydatidiform mole have, in general, a normal later pregnancy experience. After one molar pregnancy, the risk of a molar pregnancy in a later conception was about 1%. Our patients who received chemotherapy for persistent gestational trophoblastic tumor had 522 later pregnancies, which resulted in 358 (68.6%) term live births and only 10 (2.5%) major and minor congenital anomalies. Data from other centers involving 2,598 later pregnancies also indicate that after chemotherapy patients can generally anticipate a normal future reproductive outcome.

Outcome of pregnancies occurring within 1 year of hydatidiform mole.

OBJECTIVE: To determine the outcome of subsequent pregnancies in patients with partial or complete molar pregnancy who conceive before completing the recommended hCG follow-up of at least 6 months. METHODS: Retrospective record review of patients with partial or complete mole who conceived before the standard gonadotropin follow-up of 6 months was completed during 1980-1998. RESULTS: Sixty-seven patients with molar pregnancy who conceived before completion of hCG follow-up were identified. Thirty-five (52.2%) patients had a prior partial mole, and 32 (47.8%) had a prior complete mole. The mean interval from first achieving undetectable hCG level to new pregnancy was 3.1 and 3.4 months in patients with partial and complete mole, respectively. Eleven patients underwent elective termination, and 12 were lost to follow-up. Of the remaining 44 patients, 33 (75.0%) had live births, 10 had spontaneous abortions, and one had an ectopic pregnancy. A viable pregnancy outcome was achieved in 20 (83.3%) of 24 patients with partial mole and 13 (65.0%) of 20 patients with complete mole. None of the patients developed any evidence of postmolar persistent gestational trophoblastic tumor. None of the live births had any detectable fetal anomalies. CONCLUSION: The risk of persistent tumor is low and reproductive outcome is favorable once undetectable hCG levels are achieved. Pregnancies occurring before the completion of recommended hCG follow-up may be allowed to continue under careful surveillance.

Reproductive performance after conventional metroplasty: an evaluation of 102 cases.

OBJECTIVE: To evaluate the influence of conventional metroplasty on reproductive performance of symmetric uterine anomalies and determine the complications of these procedures. DESIGN: A retrospective clinical analysis of consequently operated 102 women. SETTING: Institutional. PATIENTS AND PARTICIPANTS: One hundred two patients with bicornuate and septate uterus and a history of late recurrent abortion and/or preterm delivery were included in this study. INTERVENTIONS: Jones, Strassman, and Tompkins procedures for metroplasty and McDonald operation for cervical cerclage. MAIN OUTCOME MEASURE: The fetal survival rate has increased from 3.7% before operation to 75.0% afterwards. In only two patients uterine rupture was observed. RESULTS: Conventional metroplasty improves the fetal survival rate in women with symmetric uterine anomalies. CONCLUSIONS: Our results confirm the view that conventional metroplasty seems to be an operation of choice in women with symmetric uterine anomalies and a history of recurrent late abortion and preterm delivery. However, uterine rupture and postoperative infertility may be potential complications.

Complications of radical hysterectomy in women with early stage cervical cancer: clinical analysis of 270 cases.

During a 25 year period, 270 cases of stage IB and IIA cervical cancer were subjected to radical hysterectomy and lymphadenectomy. The morbidity rate was 27.6% and mortality rate was 0.3%. While injuries to the great vessels were the most common intra-operative complications, the most frequent postoperative complications were in the urinary system. The leading causes of morbidity were bladder dysfunction (16.2%), urinary infection (5.9%), lymphocyst (6.4%) and wound infections (3.5%). While the overall complications seem high, the frequency of serious morbidity has diminished and radical hysterectomy now represents one of the accepted methods of treatment of cervical carcinoma, with good 5-year survival rates.

Management of invasive cervical cancer in patients initially treated by simple hysterectomy.

This study includes 15 patients with invasive cervical cancer found at the time of standard hysterectomy for benign conditions. All patients underwent laparotomy and were subjected to peritoneal cytology, radical parametriectomy, bilateral pelvic and para-aortic lymphadenectomy. Residual disease was found in 10 of the 15 patients (66.7%). The 3-year survival of patients with and without residual disease were 80% and 100%, respectively. Following secondary radical surgery, five patients without evidence of residual disease were identified and spared the risks of radiation therapy. Furthermore, two patients with para-aortic lymph node metastases, who would otherwise have been overlooked, were thus treated completely. One patient died of complications of secondary surgical procedure.

Prognostic value of mitotic activity, eosinophilic and inflammatory reaction in stage I cancer of the uterine cervix.

This study includes 110 patients treated surgically for stage I squamous cell carcinoma of the cervix. The prognostic significances of mitotic activity, stromal inflammatory and eosinophilic reactions were studied. The 5-year survival rate varied from 75.0% to 93.3% and pelvic lymph node metastases (PLNM) varied from 23.0% to 31.2% according to degree of these variables. None of these pathological parameters was found to be a significant predictor of pelvic lymph node metastases and 5-year survival.

Correlation between clinical and histopathologic risk factors and lymph node metastases in early endometrial cancer (a multivariate analysis of 183 cases).

This study includes 183 patients with clinical stage I endometrial cancer subjected to peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and omental biopsy during a 12-year period in a single institution. The factors analyzed were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, presence of concomitant endometrial hyperplasia and lymph node status. The overall incidences of pelvic and para-aortic lymph node metastases were found to be 15.3% (28/183) and 9.3% (17/183), respectively. In five of 17 patients (29.4%) with para-aortic nodal metastases, pelvic nodes were free of tumor. The most significant prognostic factors for positive pelvic and/or para-aortic nodes were found to be the depth of myometrial invasion, grade of tumor and age.

Gaucher's disease and pregnancy.

A 24-year-old primigravid woman with adult type Gaucher's disease was admitted at 28 weeks of pregnancy. She was asthenic and the abdomen was markedly protuberant due to hepatosplenomegaly. A conservative approach with close monitorization of both mother and baby was planned. On the 39th week of pregnancy a healthy female baby of 3000 g was delivered via cesarean section. Apart from mild hematological complications, the pregnancy, the delivery and the puerperium were uneventful.

Risk factors for recurrence in clinically early endometrial carcinoma: an analysis of 183 consecutive cases.

This study includes 183 patients with clinical stage I endometrial carcinoma. All patients had standard surgical staging procedure including peritoneal cytology, total abdominal hysterectomy, bilateral pelvic and paraaortic lymphadenectomy. The factors analysed for recurrence were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, concomitant endometrial hyperplasia and pelvic and paraaortic node metastases. The overall recurrence rate was 14.2% (26/183). Of the 26 patients with recurrence, 11 had local and 13 had distant metastases. In the remaining two patients (7.7%), both local and pelvic metastases were observed. Of the factors analysed, age, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, microscopic vaginal metastases, adnexal involvement and pelvic and paraaortic nodal metastases were found to be significant predictors of recurrence. After multivariate analysis, advanced age (RR = 1.05), marked mitotic activity (RR = 3.11), pelvic and/or paraaortic nodal metastases (RR = 6.37) were chosen as the most important determinants of recurrence. In terms of surgical pathological stages, recurrence risk reaches up to 45.4% for stage IIIC disease. Using surgical pathological parameters, it is possible to predict recurrence but because of high rate of distant failures it still seems hard to improve survival of this group. Detection of a substantial risk of recurrence even in stage IA/B grade 1 group warrants adjuvant therapy in all patients after primary surgery.

Tumor status of lymph nodes in early endometrial cancer in relation to lymph node size.

A retrospective analysis of 36 patients with metastatic nodes out of 209 consecutively managed patients with a clinically stage I endometrial cancer was carried out. Of the 1023 lymph nodes removed, 154 nodes were found to be metastatic. The mean number of the involved nodes was 4.27 (range: 1-29). Of the 154 positive nodes, 3 had nodal diameters < or = 3 mm (1.9%), 84 had diameters of 4-10 mm (54.6%), 60 had diameters of 11-20 mm (39.0%) and 7 had diameters more than 20 mm (4.5%). With increasing lymph node size, the frequency of tumoral involvement varies from 1.0% in nodes < or = 3 mm to 63.6% in nodes bigger than 20 mm. In terms of patients, nine of them were found to have a single metastatic node ranging from 6 mm to 10 mm in diameter. In the remaining 27 patients with multiple metastatic nodes, the biggest nodes encountered were 6-10 mm in 4 (14.8%), 11-20 mm in 17 (62.9%) and more than 20 mm in 6 (22.2%) patients. Since mere sampling of the lymphatic tissue directed particularly to the enlarged nodes may not show the true incidence of positive nodes, a complete lymphadenectomy is advocated in order to obviate an understaging problem.

Is routine appendectomy beneficial in the management of ovarian cancer?

A retrospective analysis of 136 patients with ovarian carcinoma subjected to appendectomy as a part of surgical procedure was carried out to assess the importance of appendectomy in patients with ovarian cancer. Of the 136 patients studied, 94 had epithelial and 38 had non-epithelial type of primary ovarian carcinoma. In the remaining 4 patients, the primary operation was performed with an intraoperative diagnosis of ovarian carcinoma but the final pathological examination revealed appendiceal carcinoma metastatic to ovaries. The overall appendiceal involvement in the study group with primary ovarian cancer was found to be 32.5% (43/132). This figure was 15.7% and 39.3% for non-epithelial and epithelial tumors, respectively. Involvement of the appendix ranged from 8.8% for patients with stage I disease to 46.0% for patients with stage III-IV disease. Four of the appendices found to be inflamed during the surgical explorations were later reported as acute appendicitis. The frequent occurrence of metastatic disease in the appendix in patients with ovarian cancer suggests routine appendectomy is appropriate for staging early cases and for contributing to maximal cytoreduction in advanced cases.

Synchronous primary malignancies of the female genital tract.

This study includes 29 patients with synchronous primary malignancies of the female genital tract. These patients constituted 1.7% of all genital malignancies. The most frequently observed synchronous neoplasms were those of the ovary together with the endometrium (51.7%). Most patients had early-stage and low-grade disease. Stage I disease was observed in 68.1% of patients with ovarian cancer. Patients with synchronous ovarian and endometrial cancer had a 73.3% 5-year survival rate, suggesting a favorable prognosis.

Risk factors for groin node metastasis in squamous carcinoma of the vulva: a multivariate analysis of 39 cases.

This study includes 39 patients with squamous carcinoma of the vulva subjected to radical surgery. Stage, tumor description, cell type, lesion localization, lesion size, depth of invasion, grade, lymphovascular space invasion, number of mitoses, degree of stromal inflammatory reaction, and tumors in surgical margins were analyzed for groin metastasis. Of the factors analyzed, stage (P = 0.018), grade (P = 0.007) and depth of invasion (P = 0.001) were found to be the most important predictors of node metastasis. While a combination of factors permitted to define a low-risk group with 0% node metastasis, it seems hard to identify preoperatively those patients with no risk of nodal metastasis.

Struma ovarii.

OBJECTIVE: To review the clinicopathological experience of patients with benign and malignant struma ovarii. METHOD: A retrospective institutional analysis of 2 patients with malignant and 14 patients with benign struma ovarii, treated during a period of 20 years. RESULT: The patients with struma ovarii constituted 1.0% of all ovarian neoplasms in our institution (16/1501). Four percent of the germ cell tumors were calculated to be of struma ovarii (16/382). The stages of the malignant cases were recorded as 1A and 1C. Besides detection at early stage, a biologically low grade tumor was encountered as well. Although 5 of the patients had goitre, none of them had hyperthyroidism. None of the patients had a bilateral tumor. However, in 2 patients, a serous cystadenoma and dermoid cyst were found in the contralateral ovaries. The preoperative and intraoperative diagnosis of malignant struma ovarii proved to be difficult since 2 patients subjected to radical surgery according to suspicious frozen section reports in this series later were found to be benign struma ovarii. CONCLUSION: The low metastatic potential and slow progression rate of malignant struma ovarii support conservative surgery especially in young patients who have not yet completed their families.

Balloon valvuloplasty during pregnancy.

Although rheumatic diseases are reported to be almost eradicated in the developed countries, they still continue to contribute significantly to maternal mortality in the developing world. Surgical therapies need to be considered for those patients who do not respond satisfactorily to medication. However, valve replacement or valvulotomy during pregnancy carries significant risks for both the mother and the fetus. Two patients with severe mitral stenosis refractory to medical therapy are presented. Both patients were subjected to percutaneous balloon valvuloplasty during pregnancy without any complications. They were able to discontinue medication and deliver vaginally at term. Balloon valvuloplasty appears to be a safe alternative to conventional surgical approaches in pregnancy.