AB0 Blood Group and Ovarian Cancer Survival.

Background: Epithelial ovarian cancer is the most lethal gynecological malignancy because is usually diagnosed at advanced stage. New prognostic factors have been investigated but these biomarkers do not have a strong direct relationship with survival. Several studies investigated the association between AB0 blood group with ovarian cancer but with conflicting results. We investigated the association between AB0 blood group and epithelial ovarian cancer patients consecutively surgically treated at our department from 2004 to 2015. Methods: Clinical charts of ovarian cancer patients treated and followed from 2004 to 2015 were checked for inclusion and exclusion criteria. Clinical and pathological data were recorded in an electronic separate, anonymous, password-protected database. All relevant data were extrapolated and used for final analysis. Results: A population of 265 ovarian cancer patients was analyzed in this study. 121 (45.6%) patients presented blood type 0, 112 (42.3%) had blood type A, 23 (8.7%) B and 9 (3.4%) AB. A significantly lower percentage of death (8.7%) in patients with blood type B in comparison with patients presenting different genotypes (group 0: 34.7%, group A: 32.1%, group AB: 22.2%) was found. In invasive serous ovarian cancer patients the analysis showed a 5 fold significant reduction of the risk of death in patients with B genotype. However, postoperative residual tumor resulted the most important prognostic factor for overall survival. Conclusions: AB0 blood group might be a preoperative prognostic factor in epithelial ovarian cancer patients. According to the literature, postoperative residual disease remain the most important prognostic factor also in our study.

Uterine Papillary Serous Carcinoma Arising in a Polyp: A Multicenter Retrospective Analysis on 75 Patients.

OBJECTIVES: The objectives of this study were to evaluate whether the international recommendations on the management of uterine papillary serous carcinoma arising in a polyp are uniformly followed in Italian Oncologic Centers and whether the strategy adopted is effective. MATERIALS AND METHODS: Patients with uterine papillary serous carcinoma arising in a polyp and who had undergone a hysterectomy were identified in the 2003-2013 database of 7 Italian Gynecologic Oncology Centers. Clinical and pathologic characteristics and outcomes were compared between staging procedure types. Survival curves of the women were plotted using the Kaplan-Meier method and analyzed using Cox regression hazard model and the log-rank test. Associations between clinical parameters and the incidence of recurrence were assessed by generalized linear models and the Fisher test. RESULTS: A total of 75 patients met the inclusion criteria. Recurrence-free survival was affected positively by type of surgical staging and negatively by preoperative diagnosis of hypertension. The association between surgical staging and recurrence-free survival resulted significant at univariate survival analysis (P=0.048 and 0.045) and maintained a trend of significance (P=0.070) in multivariate analysis, whereas hypertension was demonstrated to be the principal influencing factor. CONCLUSIONS: The international recommendations on the management of uterine papillary serous carcinoma are not uniformly followed in daily practice, although the extension of the surgery seems to be associated with lower recurrence rates also when uterine papillary serous carcinoma is confined to a polyp or endometrial surface.

Prognostic Impact of ABO Blood Group on Type I Endometrial Cancer Patients- Results from Our Own and Other Studies.

Objectives: The ABO blood group antigens were found on most epithelial cells and in secretions. In the normal endometrium there is a variable expression of histo-blood group and related antigens suggesting a hormonal regulation. A relationship between ABO blood groups and endometrial cancer has been investigated with contradictory results. In this study we investigated the influence of blood types on clinical and pathological characteristics of endometrial cancer patients. Method: Retrospective cohort study. Clinical and pathological data were extrapolated and their association with blood groups were assessed. Results: A total of 203 type I endometrial cancer patients were included in the final analysis. Univariate analysis indicated that a lower frequency of G3 undifferentiated tumors was observed in patients with A blood group (P=0.027). Multivariate analysis, including also clinical features such as Age, BMI, parity, hypertension and diabetes confirmed that patients with A group present a lower risk of G3 tumors in comparison with not A patients. (OR=0.32, P=0.011). Conclusions: Patients with A genotype have a lower risk to develop G3 type I endometrial cancer. ABO blood group might represent a useful, easy access and cheap biomarker for patients' selection and for management personalization of endometrial cancer patients.

Impact of the Food and Drug Administration Safety Communication on the Use of Power Morcellator in Daily Clinical Practice: An Italian Survey.

STUDY OBJECTIVE: To assess the impact of the Food and Drug Administration (FDA) warning about power morcellation use on the daily clinical practice of Italian gynecologists. DESIGN: Electronic survey mailed to the main gynecologic centers (Canadian Task Force Classification type III). SETTING: Unit of Obstetrics and Gynecology, IRCCS - Arcispedale S. Maria Nuova di Reggio Emilia (Italy). PATIENTS: The study did not include patient data. INTERVENTION: There was no intervention. MEASUREMENTS AND MAIN RESULTS: From 490 surveys sent out, 426 replies were included in the final analysis (return rate = 86.9%). Four hundred of the 426 (93.9%) gynecologists were aware of the FDA warning. One hundred fifty of 302 (49.7%) of experienced gynecologists and 176 of 349 (50.4%) of oncology gynecologists considered laparoscopy the best approach for myomectomy. The FDA communication was considered overly restrictive by experienced and oncology gynecologists who declared that they had no intention of changing their surgical approach. Two hundred fifty of the 426 (58.7%) gynecologists declared that they would change their surgical approach only to prevent legal litigation. CONCLUSION: The FDA warning also affected Italian gynecologists. Particularly, less experienced gynecologists and those without oncologic practice seem to be more interested in avoiding legal litigation rather than a real clinical risk of upstaging an unexpected leiomyosarcoma. Fear of undiagnosed sarcoma could increase the number of laparotomies.

Cellular angiofibroma in women: a review of the literature.

Cellular Angiofibroma (CA) represents a quite recently described mesenchymal tumour that occurs in both genders, in particular in the vulvo-vaginal region in women and in the inguino-scrotal area in men. The first description of this tumour dates from Nucci et al. article in 1997; since then, the literature reports different reviews and case report of this tumour in both genders, but no article specifically addressing CA treatment and follow-up in women. In this review we collected all 79 published female CA cases, analyzing the clinical, pathological and immunohistochemical features of the tumour.CA affects women mostly during the fifth decade of life, it is generally a small and asymptomatic mass that mainly arises in the vulvo-vaginal region, although there are reported pelvic and extra-pelvic cases. The treatment requires a simple local excision due to an extremely low ability to recurrent locally and no chance to metastasize. Throughout the immunohistochemical and pathological findings it is also easily possible a differential diagnosis from the other soft tissue tumours which affect the vulvo-vaginal area, such as spindle cell lipoma, solitary fibrous tumour, angiomyofibroblastoma and aggressive angiomyxoma.

Polymorphisms in cyclooxygenase-2 gene in endometrial cancer patients.

The enzyme cyclooxygenase 2 is an inducible enzyme expressed at sites of inflammation and in a variety of malignant solid tumors such as endometrial cancer (EC). In EC patients, its over-expression is correlated with progressive disease and poor prognosis. The expression is encoded by a polymorphic gene, called PTGS2. The aim of the current study was to test the hypothesis that rs5275 polymorphism of PTGS2 influence the prognosis of EC patients. This paper is a retrospective cohort study. Clinical and pathological data were extrapolated and genotypes were assessed on formalin-fixed and paraffin-embedded non-tumor tissues. A total of 159 type I EC patients were included in the final analysis. Univariate analysis indicated that patients with rs5275 genotype CC have a lower risk to develop a grade (G) 2-3 endometrial cancer. rs5275 effect on EC grading was confirmed by multivariate analysis also after data adjusting for age, BMI, parity, hypertension, and diabetes. Adjusted odds ratio (OR) confirmed that patients with rs5275 genotype CC have a risk 80 % lower (OR = 0.20, P = 0.009) to develop a G2 and/or G3 EC in comparison with patients with TT or TC genotype. Differentiation of the type 1 EC is significantly and independently influenced by rs5275 polymorphism. rs5275 CC patients have a lower risk to present a G2-G3 EC.

HNF1B polymorphism influences the prognosis of endometrial cancer patients: a cohort study.

BACKGROUND: HNF1B (formerly known as TCF2) gene encodes for a transcription factor that regulates gene expression involved in normal mesodermal and endodermal developments. A close association between rs4430796 polymorphism of HNF1B gene and decreased endometrial cancer (EC) risk has been demonstrated. The aim of the current study was to test the hypothesis that rs4430796 polymorphism can influence the prognosis of EC patients. METHODS: Retrospective cohort study. Clinical and pathological data were extrapolated and genotypes were assessed on formalin-fixed and paraffin-embedded non-tumour tissues. The influence of patients' genotype on overall survival and progression free survival were our main outcome measures. RESULTS: A total of 191 EC patients were included in the final analysis. Overall survival differed significantly (P = 0.003) among genotypes. At multivariate analysis, a significant (P < 0.05) effect on overall survival was detected for FIGO stage, and rs4430796 polymorphism of HNF1B gene. After grouping EC patients according to adjuvant treatment, rs4430796 polymorphism resulted significantly (P < 0.001) related to overall survival only in subjects who received radiotherapy plus chemotherapy. A significant (P = 0.014) interaction between rs4430796 polymorphism and chemo-radiotherapy was also detected. Finally, only a trend (P = 0.090) towards significance was observed for rs4430796 polymorphism effect on progression free survival. CONCLUSIONS: rs4430796 polymorphism of HNF1B gene influences independently the prognosis of EC patients with a potential effect on tumor chemo-sensitivity.

Coxalgia? Call the gynecologist.

Cellular angiofibroma is a rare mesenchymal tumor that usually affects the vulvar region. It is commonly asymptomatic and treated with radical excision. We describe the first case of cellular angiofibroma located in the retroperitoneum presenting with coxalgia and laparoscopically treated. At the 6-month follow-up, the patient was coxalgia and disease free. Coxalgia is an unusual symptom for gynecologists; nevertheless, it is possible that several neoplasms may originate in the female pelvis, so any symptom requires careful evaluation. The laparoscopic approach may be effective in removing cellular angiofibroma, avoiding injuries to surrounding structures and unesthetic scarring and leading to a faster recovery.

Primary diffuse large B-cell lymphoma of the uterus: case report and review.

BACKGROUND: Primary diffuse large B-cell lymphoma of the cervix is a very rare disease, with non-specific clinical presentation. Its prognosis depends on accurate and timely diagnosis and therapy. Moreover, the management of this tumour has never been standardized. CASE REPORT: Herein we present a rare case of primary diffuse large B-cell lymphoma of the cervix misdiagnosed as cervical myoma. Our systematic review of the English literature identified 143 cases of primary diffuse large B-cell lymphoma of the uterus. Patients' characteristics and oncological, surgical, and safety data were recorded and analyzed. CONCLUSION: Although rare, primary diffuse large B-cell lymphoma of the cervix should never be ruled-out. Given its non-specific clinical symptoms, a multidisciplinary approach is required to perform a timely diagnosis and administer appropriate therapy. Immunochemotherapy (Rituximab + CHOP or CHOP-like regimen) with/without radiotherapy is the most common and most effective treatment; surgery should be avoided.

Clinical governance network for clinical audit to improve quality in epithelial ovarian cancer management.

BACKGROUND: Epithelial ovarian cancer (EOC) is the most lethal gynecological cancer. Several hospitals throughout the region provide primary treatment for these patients and it is well know that treatment quality is correlated to the hospital that delivers. The aim of this study was to investigate the management and treatment of EOC in a Region of the North Italy (Emilia-Romagna, Italy). METHODS: A multidisciplinary group made up of 11 physicians and 3 biostatisticians was formed in 2009 to perform clinical audits in order to identify quality indicators and to develop Region-wide workup in accordance with the principles of evidence-based medicine (EBM). The rationale was that, by setting up an oncogynecology network so as to achieve the best clinical practice, critical points would decrease or even be eliminated. Analysis of cases was based on the review of the medical records. RESULTS: 614 EOC patients treated between 2007 and 2008 were identified. We found only 2 high-volume hospitals (≥ 21 patients/year), 3 medium-volume hospitals (11-20 operated patients/year), and 7 low-volume hospitals (≤ 10 operated patients /year). Only 222 patients (76.3%) had a histological diagnosis, FIGO surgical staging was reported only in 206 patients (70.9%) but not all standard surgical procedures were always performed, residual disease were not reported in all patients. No standard number of neoadjuvant chemotherapy cycles was observed. CONCLUSIONS: The differences in terms of treatments provided led the multidisciplinary group to identify reference centers, to promote centralization, to ensure uniform and adequate treatment to patients treated in regional centers and to promote a new audit involving all regional hospitals to a complete review of the all the EOC patients.

Haptoglobin phenotype and epithelial ovarian cancer.

BACKGROUND: Haptoglobin (H) is a glycoprotein that regulates the immune response. Serum haptoglobin levels are significantly higher in patients with advanced epithelial ovarian cancer (EOC) with poor survival. Different isoforms of haptoglobin have been found in the serum of patients with EOC. We studied the genetic susceptibility and outcome of patients with EOC correlated to H phenotypes. MATERIALS AND METHODS: Analyses of the H phenotypes were performed on sera from patients stored at -70°C. A modified method based on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of sera was used, followed by western blotting. RESULTS: Seventy-nine consecutive patients with EOC and 63 healthy women were enrolled. Their mean (± S.D.) age was 58.9 ± 12.46 years. Overall survival was 66 months (95% confidence interval=37.7-94.2). Similar distribution of haptoglobin phenotypes was observed in EOC and in healthy women. No significant correlation was found between haptoglobin phenotype, overall survival and time-to-progression. Fewer G3 tumors were found in patients with H2-2 compared with those with H1-2 (84.2% and 90.6%, respectively, p<0.04). No significant correlation was found between H phenotype and tumor markers or number of relapses. CONCLUSION: Although ours is a preliminary study based on a small population with scant significant findings, we hypothesize that patients with EOC with haptoglobin 2-2, might have a better prognosis because they present fewer G3 tumors and they may present a stronger immune response than patients with 1-1 and 1-2 phenotypes. Larger studies should be performed to assess the predictive value of haptoglobin phenotype in patients with EOC.

Laparoscopic versus abdominal approach to endometrial cancer: a 10-year retrospective multicenter analysis.

OBJECTIVE: The objective of this study was to give a reality-based picture of the use of laparoscopic surgery for staging endometrial cancer patients out of the experimental setting. METHODS: Consecutive data of patients with endometrial cancer who underwent laparoscopic or abdominal surgical staging in 6 Italian centers were recorded. Baseline patients and tumors characteristics, surgery performed, and safety data were collected and analyzed. RESULTS: A total of 1012 subjects (403 and 609 treated by laparoscopy and laparotomy, respectively) who received surgical stadiation for endometrial cancer were included in the final analysis. The laparoscopic approach to endometrial cancer was more commonly performed in younger and nonobese patients who had received less previous surgeries, whereas the abdominal approach was preferred for the advanced stages and rare histotypes. Irrespectively to stage, the operative time was higher for the laparoscopy than laparotomy, whereas blood loss and postoperative complications were lower in the laparoscopy group than in the laparotomy group. No difference between surgical approaches was observed in complication rates in stage I endometrial cancers, whereas they were worst in higher stages. The site, but not the incidence, of recurrences differed only for advanced stage endometrial cancers. No differences in overall, disease-free, and cancer-related survival rates were also observed. CONCLUSIONS: In the clinical practice, heterogeneous criteria are adopted to recur to laparoscopy for staging endometrial cancer. The safety and the feasibility of the laparoscopy are confirmed for stage I endometrial cancers, whereas they appear suboptimal for the advanced stages.

Myelomeningocele and pregnancy: a case report and review of the literature.

The improvement of antenatal management and surgical techniques has greatly increased the survival rate of infants with spina bifida. More of these women are reaching adulthood and reproductive age and therefore could become pregnant. Pregnancy complications depend on the kind of spina bifida and subject's condition.We report a case of woman with a severe kyphoscoliosis, that progressively affects lung capacity until 32 weeks of gestation, when she underwent caesarean section.These patients deserve careful obstetric care, genetic counselling and urological, obstetric, neurological and anaesthetic management.

Province wide clinical governance network for clinical audit for quality improvement in endometrial cancer management.

BACKGROUND: According to the hub-and-spoke model introduced in the Provincial Healthcare System of Reggio Emilia, early endometrial cancer is treated in peripheral low-volume hospitals (spokes) by general gynecologist, whereas more complex cancers are treated by gynecological oncologists at the main hospital (hub). OBJECTIVE: To guarantee a uniformly high standard of care to all patients with endometrial cancer treated in hub and spoke hospitals of Reggio Emilia Province. METHODS: The specialists of the 5 hospitals of Reggio Emilia Province instituted an inter hospital and multidisciplinary oncology group to write common and shared guidelines based on evidence-based medicine through the use of clinical audit. They valued the process indicators before and after guidelines introduction identifying the site of improvement and verifying the standard achievement. RESULTS: Diagnostic hysteroscopy use increased significantly from preguideline period, 53%, to postguideline period, 74%. Magnetic resonance use and accuracy increased significantly from preguideline to postguideline periods: 8.1% to 35.3% and 37.3% to 74.7%, respectively. Laparoscopy use increased from 1.6% (preguideline) to 18.6 (postguideline). Early surgical complications decreased from 16% (preguideline) to 9% (postguideline). Radiotherapy use increased from 14.% (preguideline) to 32.3% (postguideline). CONCLUSION: It is possible for a provincial oncology group to build an oncology network providing an improvement in the assistance of patients with endometrial cancer through the use of clinical audit. Clinical audit made it possible to obtain the full attendance of specialists of various disciplines involved in the treatment of endometrial cancer to optimize response time schematizing process.

Colouterine fistula complicating diverticulitis diagnosed at hysteroscopy: case report.

Since Noecker first reported a colouterine fistula secondary to diverticulitis in 1929, about 20 cases have been reported in the literature. Methods for diagnosis have yet to be established. Herein we report the first case of a colouterine fistula at the level of the isthmus diagnosed at hysteroscopy. Diagnostic hysteroscopy enabled rapid diagnosis of the colouterine fistula. Diagnostic hysteroscopy is the first-choice diagnostic tool for investigation of any abnormal vaginal discharge such as blood or stool because it enables direct vision and biopsy of the lesions of the lower genital tract quickly and at low cost.

Protein expression patterns associated with advanced stage ovarian cancer.

This is a comparative proteomic study on biopsies from patients with ovarian cancer to identify potential diagnostic/prognostic biomarkers in both healthy and tumor tissue, interstitial fluid (normal interstitial fluid and tumoral interstitial fluid and peritoneal effusion. Protein expression/identification was evaluated by 2-DE and MS analysis: six proteins showed differential expression in tumoral interstitial fluid and tumor tissue compared to normal interstitial fluid and healthy tissue: five were found to be downregulated and identified as galectin 3, glutathione S-transferase A-2, retinol binding protein 1, phosphatidylethanolamine-binding protein and annexin 5, while the calgranulin, was significantly upregulated in all pathological samples, including the ascitic fluid. Validation of S100A8 overexpression in carcinoma tissue was obtained by immunohistochemistry. To our knowledge, this is the first study to report an over-expression of calgranulin by 2-DE associated with MS/MS analysis on surgical biopsy. The reduced expression of galectin 3 and retinol binding protein 1 in cystic fluid and serum of patients with early stage disease is confirmed in this study. The results highlight alterations in proteins that control cell-cycle progression and apoptosis, as well as factors that modulate the activity of signal transduction pathways. Moreover, this study suggests that calgranulin expression may be used as a diagnostic and/or prognostic biomarker.

Multifocal PEComa (PEComatosis) of the female genital tract associated with endometriosis, diffuse adenomyosis, and endometrial atypical hyperplasia.

The authors describe a case of multifocal perivascular epithelioid cell tumor (PEComa) arising in the pelvis of a 39-year-old woman affected by tuberous sclerosis. The tumor presented in the form of multiple fascicular, focally cystic nodules involving the uterine corpus, both ovaries, and the omentum. Microscopically, the nodules were composed of foci of adenomyosis and endometriosis (with focal atypical complex hyperplasia) associated with a stromal spindle cell population immunoreactive for HMB-45, smooth muscle actin, and estrogen and progesterone receptors. We interpret these foci as the result of a widespread proliferation of perivascular epithelioid cells (PEC). Because of the diffuse quality of the process, the designation of PEComatosis seems warranted.