The first case of breast cancer in thalassemic patient: case report and review of literature.

Thalassemias are genetic disorders characterized by decreased synthesis of one of the globin chains. Beta-thalassemia is caused by impairment in the production of beta-globin chains leaving the excess alpha chains unstable. With better treatment approaches and improvement in chelation therapy, thalassemic patients are living longer. As a consequence, new complications and associations with other conditions including malignancy have emerged. The occurrence of malignancies in thalassemia has rarely been reported, and our review of the literature revealed only few cases. We report the first case of a thalassemic patient developing breast cancer and discuss the possibility of a link between the two disease entities. This case is intended to alert physicians of the possibility of a malignancy in thalassemia patients.

Chlamydia trachomatis prevalence in North-West Italy.

AIM: Chlamydia (C.) trachomatis infection is the most common sexually transmitted disease (STD) among sexually active adolescents and young adults in Europe. The aim of this study was to determine the prevalence of C. trachomatis among sexually active women in Piedmont, Italy and the correlation between some risk factors and C. trachomatis infection. METHODS: In our study 31,419 sexually active women aged 12-55 were screened for C. trachomatis by Abbott's ligase chain reaction (LCR) using cervical swabs during the period 1997-2001 at St. Anna Obstetric-Gynecological Hospital, Turin. All the patients answered a specific questionnaire. RESULTS: In our analysis the prevalence of C. trachomatis infection was found to be 1.23%, and the average age among the infected patients was 36.98 years. Statistical analysis was performed using the chi squared test; a p<0.05 was considered significant. A correlation was found between a positive test result and the age at the first intercourse (p<0.001), the number of sexual partners in the preceding 6 months (p<0.001), the presence of symptoms (p<0.001), a low level of education (p<0.001) and an East-European and Central-Northern African citizenship (p<0.001). No statistically significant differences were found among the contraceptive methods used, whether an hormonal or a barrier type; a marked increment of the risk was observed when no contraception was used. CONCLUSION: Frequent microbiological examinations are desirable for patients whose anamnesis shows an augmented risk of contracting sexually transmitted infections in order to avoid long term complications from misdiagnosed or asymptomatic pathologies, as often happens with C. trachomatis.

[Congenital hepatic fibrosis in pregnancy]. / Su un caso di fibrosi epatica congenita in gravidanza.

The purpose of this study was to analyse the course of pregnancy of a 20-year-old woman suffering from congenital hepatic fibrosis (CHF), a genetic disease with recessive autosomic transmission, attributed to the group of hepato-nephro-pancreatic fibropolycystic familial diseases. This was the only time such a case had ever been encountered in a pregnancy in the history of Turin University's Obstetrics and Gynaecological Clinic. The case of a 20-year-old woman is considered. She was admitted to our observation at the Obstetrics and Gynaecological Department of Faculty "B" of the University of Turin, suffering from CHF, a primigravid in the eighth week of gestation. Haematochemical tests carried out on the patient showed a platelet deficiency without evident changes in liver and renal function. Objective examination revealed a slight hepatosplenomegaly confirmed by abdominal echotomography. The haematochemical examinations subsequently carried out confirmed thrombocytopenia due to hepatosplenic hyperhaemocataresis. In agreement with the will of the patient and her family, and after having heard the opinion of our hospital's anaesthetists and internists, a conservative approach was decided on and close monitoring of maternal and foetal conditions was planned, with hospitalisations scheduled for every fortnight. Together with the internists and anaesthetists, it was decided to allow the pregnancy to proceed as far as foetal maturity but not to term, to avoid problems relating to the excessive increase in uterine volume which would have led to pressure on the portal tree and so favoured haemorrhaging due to rupture of the oesophageal varices. Caesarean delivery was planned for the 37th week of gestation. The birth went according to plan and the foetus was a live, vital male with Apgar index of 9/9. The placenta presented normal characteristics and a weight of 590 g. No haemorrhagic complications were observed either in the course of surgery or in the postoperative phase, notwithstanding the preoperative finding of a platelet count of 64,000 platelets/ mm3. Although in our case neither the pregnancy nor the delivery constituted a serious danger for the life of the mother, possible obstetric complications are among the most serious encountered in obstetric pathology and can lead both to maternal death and to the intrauterine death of the foetus. For these reasons we believe it essential to provide correct, clear and adequate information about the risks involved for patients suffering from congenital hepatic fibrosis, especially if they are associated with renal polycystic disease, and who are admitted to our wards with the desire to programme a pregnancy.

[A new method of neovagina in Rokitansky's syndrome. A review of the literature and description of a series]. / Proposta di nuova metodica di neovagina nella sindrome di Rokitansky. Revisione della letteratura ed illustrazione della casistica.

BACKGROUND: The absence or hypoplasia of the vagina is a frequent finding in Rokitansky-Mayer-Küster-Hauser syndrome. METHODS: A group of 13 patients with Rokitansky-Mayer-Küster-Hauser syndrome were treated between 1982 and December 2001 at the Plastic Surgery Department of C.T.O. (Turin) and the 2nd Obstetrics-Gynecology Clinic of Turin University. Surgery was the proposed therapy in all patients, using a modified version of the McIndoe technique. RESULTS: In this series, the cytological tests of neovaginal tissue carried out one year after surgery showed a syndrome of slight atrophy in 8 cases, but this was not sufficient to impede the sexual activity of these patients. Two patients were lost in the follow-up; 3 patients declared that they were reasonably satisfied with their sex life, whereas the remaining 8 reported a normal sex life. CONCLUSIONS: The treatment of choice for complete vaginal agenesia is a neovagina using the skin graft method. This technique produces excellent anatomical results, especially in young patients, even without regular dilatation or frequent sexual relationships. The only drawback of this method is that the vagina tends to retract in some patients, a problem that has been largely solved by the most recently proposed surgical variants.

[Consent to transfusion of blood and hemoderivatives]. / Consenso alle trasfusioni di sangue ed emoderivati.

The transfusion of blood or hemoderivatives is a medical procedure that necessarily involves the possibility of danger or damage, given that, even with maximum prudence, diligence and expertise, it is impossible to avoid severe risks of infections, transfusional reactions, alloimmunisation, undesired immunomodulating effects, etc. Article 19 of Ministerial Decree 15/01/1991 makes it obligatory to obtain informed consent , understood as the free expression of the acceptance of treatment provided after being fully informed of the nature, possibility, risks and collateral effects of the procedure. Consent to blood transfusion can only be given by a person with full mental faculties, whereas transfusion treatment can be proposed for a minor, for a prisoner or for a person who is temporarily incapacitated by their physical conditions. The authors examine a number of problems regarding the following questions: what happens if consent is withheld? What can happen if consent is not requested or if the transfusion is performed when consent has been denied? In conclusion, it is difficult to offer operating schemes that are easy to apply: much depends on the patient's conditions, his reactions, his concerns, his trust in the doctor and the latter's communication skills.

[Delivery in multiple pregnancies]. / Il parto nelle gravidanze multiple.

BACKGROUND: A knowledge of clinical physiognomy in pathologies related to multiple births is indispensable for improving maternal and feto-neonatal prognosis. This study is a contribution to the solution of this problem. METHODS: A meta-analysis of data for multiple births at Department B of the Gynecology and Obstetrics Clinic at the University of Turi during the decade 1989-1998 was carried out, focusing on the arrangement and presentation of fetuses, the various types of birth, the gestational age at which birth occurred, the weight of neonates, neonatal mortality and maternal morbidity. RESULTS: Out of 11,523 births, there were a total of 194 (1.68%) multiple births, including 190 sets of twins and 4 triplets. 154 (79.38%) premature births were reported; 20 occurred <32(nd) week (10.29%). There was a high incidence of podalic presentation (26.30%) and shoulder presentation (5.61%) among twins; 202 were delivered using a cesarian section (51.53%) and 190 by vaginal birth (48.47%), of which 172 (90.52%) spontaneously. Surgical birth was an important means of extracting fetuses rapidly from a pathological environment. two hundred and sixty-two neonates (66.84%) were LBW (<2500 g), including 28 (7.14%) VLBW (>1500 g). The perinatal mortality rate was 3.82%. Maternal complications mainly occurred during the placental state, in the immediate postpartum and in puerperio. CONCLUSIONS: The authors feel that a more careful medical and social assistance, preventive hospitalisation, early recognition of the risk, constant monitoring for the optimal timing of birth, and lastly, qualified medical assistance during labour (expert gynecologist, trained obstetric staff) with other medical personnel (anesthetist, neonatal specialist) represent winning strategies to solve the problems arising during multiple pregnancies.

Pathologic features of endometrial carcinoma in elderly women.

It has been estimated that more than two-thirds of cancers occur in people over 65 years of age: endometrial cancer (EC) is the most common gynaecologic cancer in the U.S. and represents the fourth most common malignancy in women. Some authors have reported that EC in elderly women was more aggressive, histologically less-differentiated and often non-endometrioid when compared with EC in the younger population. The purpose of this retrospective study is to evaluate the pathologic features of EC in women 70 years old or over compared with those of younger patients. Between 1987 and 1997, 174 patients with EC were surgically treated: 52 women were 70 years old or over. Two-thirds of both groups had surgical Stage I tumors: 54% of surgical Stage I tumors in the elderly had myometrial invasion more than 50% compared with 32% in the younger group (p<0.01). On the whole 37% of elderly patients had Stage IC tumors compared with 21% in younger women (p<0.01). Seventy-five percent of elderly women had Grade 2 or 3 tumors compared with 55% of younger patients (p<0.005). The majority of EC was endometrioid in both groups: 8% of elderly patients had clear-cell carcinomas compared with 4% of younger women (p not significant). No elderly patients showed nodal metastasis (0 out of 10): 9% of younger women had pelvic or para-aortic metastasis. The median follow-up was 78 months. The overall survival in the elderly and in the younger group was 80% and 93%, respectively (p<0.01): in elderly women overall survival significantly varied according to histotype and depth of myometrial invasion in Stage I tumors. In conclusion patients 70 years old or over have a high probability of surgical Stage I EC but a significantly higher probability of deep myometrial invasion and less-differentiated tumors than younger women: the prognosis w as good but poorer than for younger patients.

[Amniotic fluid embolism in trial of labor. A case report]. / Embolia amniotica in travaglio di parto. Descrizione di un caso.

Amniotic fluid embolism is a rare complication of pregnancy, which accounts for about 10% of all maternal deaths. A case of acute embolic episode occurred during labor in a 36-year-old patient with spontaneous rupture of membranes is described. Caesarean section was performed immediately, followed by hysterectomy; the baby survived but the mother died because of DIC and cardiorespiratory arrest.

Perioperative prophylaxis in abdominal and vaginal hysterectomy.

The aim of this study is to evaluate the clinical efficiency of perioperative short-term prophylaxis in gynecological surgery, in order to prevent both systemic and local infections, caused either by aerobic or by anaerobic bacteria. A group of 320 patients, undergoing abdominal or vaginal hysterectomy and treated with perioperative antibiotic prophylaxis is compared, with 320 women undergoing conventional wide-spectrum antibiotic treatment from the first post-operative day for 4-5 days.

[Cervix cerclage. A 20-year case load]. / II cerchiaggio cervicale. 20 anni di casistica.

Uterine cervical incompetence is the most common cause of habitual abortion in the second trimester of pregnancy and premature delivery; cervical cerclage still represents the only surgical treatment for cervical incompetence. In the last 20 years (1971-1990) we performed 272 Mac Donald cervical cerclages in patients between the 8th and the 34th week of pregnancy. In 16 cases the outcome of pregnancy is unknown; 198 women (73.3%) subsequentely delivered healthy infants later than 37 weeks' gestation or weighing more than 2500 g.

Pre-surgical treatment of uterine myomas with LH-RH agonists.

Twenty-five non-menopausal women with uterine myomas were treated with LHRH-analogues for 3-6 months. An average reduction of 40% in uterine volume was observed. One patient refused to complete her therapy, three had no more menses after the interruption of treatment, nine underwent myomectomy within four weeks of their final administration, while in 12 cases hysterectomy was performed. In all cases the decrease in uterine volume induced by the analogue allowed a more limited intervention and prevented excessive blood loss.

[Comparison of metroplasty by Strassman's method and by Tomkins' method. Retrospective study of 30 years]. / Confronto tra metroplastica sec. Strassman e sec. Tompkins. Studio retrospettivo di 30 anni.

The study aimed to evaluate the usefulness of metroplasty to improve gestational ability in the presence of uterine malformations. From the analysis of results, it is clear that this surgical operation is undoubtedly efficacious when performed in selected patients (earlier negative obstetric outcome). The comparison of the two techniques (Strassman vs Tompkins) confirms that the latter produced better results in this series of patients.

[Neuroendocrine factors in postpartum blues]. / Fattori endocrini nei postpartum blues.

A very considerable proportion of women, estimated from 50 to 80 per cent, experience a noticeable period of emotional distress, usually mild or transistor, between the third and the tenth day postpartum (postpartum blues: PPB). The onset of this syndrome conform to a practically immutable of timing-symptoms are almost never noted before the third day postpartum (latent period). After this period, in approximately 10 per cent of women, occurs a depression: postpartum depression (PPD), and last to 8 weeks. Neuro endocrine factors in the pathogenesis of postpartum depression is discussed: thyroid, pituitary and adrenal cortex are reviewed. Considerable evidence support that the late postpartum syndromes are associated to psychological stress of childbirth with postpartum decrease of placental steroids, estrogen and progesteron, with high levels of pituitary prolactin.

[Early puerperal depression: the puerperal blues]. / La depressione puerperale precoce: i blues puerperali.

The incidence and morbidity factors as regards non-psychotic depression during the puerperium (puerperal blues or maternity blues or post-partum blues) has been investigated in 50 females at random. Puerperal blues was diagnosed as the presence of depression in keeping with Kellner's symptomatic questionnaire. Approximately two-thirds of women experience depression during the early puerperium. Primiparas, patients who have had traumatic delivery (cesarean delivery) and those who have had considerable traumatic experience during pregnancy, and/or presented a previous history of psychopathological disorders, are more subject to puerperal blues.

A case of struma ovarii in a 92-year-old woman.

A case of struma ovarii in a 92-year-old patient with altered thyroid function is reported.

Treatment failure in cervical cancer: high risk factors of relapse.

Actuarial survival in 178 patients treated with radical surgery and lymphadenectomy from 1977 to 1987 have been evaluated. The survival rate at 60 months in the 124p N0 patients was 95%; in the 57 p N1 patients was 20.2%. The survival in patients with only 1 or 2 metastatic lymph nodes was 39.7%, while it was 13.1% with 3 or more lymph nodes involved. Survival rate related to lymph nodal metastatic level was 36%, 32%, 17% respectively when the first, second and third levels were involved. We demonstrated a statistically significant relation between survival and external thirds, CLS, vaginal, parametrial invasion. A multifactorial analysis also showed the remarkable significance of the simultaneous negativity of vaginal, CLS, external third invasion (survival rate 98.4%). When the positivity of the external invasion was associated with simultaneous negativity of vaginal and CLS invasion the survival rate was 79.4%. The survival rate in patients with positive vaginal and external third invasion was 26%. This showed the decisive importance of vaginal invasion in cervical cancer survival.

Lymph nodal metastases and pathological patterns in cervical cancer: a critical review.

We analyzed 8 pathological factors in order to recognize which of them are statistically significant in worsening the stage of cervical cancer. Three factors (external third invasion, CLS, parametrial invasion) are highly significant (p less than 0.001) as regards lymphatic metastases, while no one statistical relation has been found among grading or histotype and cervical canal invasion. Comparing the 8 pathologic factors among themselves, we have observed that parametrium, corpus and CLS are highly related to external third (p less than 0.001); in the same way corpus is related to cervical canal and parametrium to CLS (p less than 0.001).

Pelvic and para-aortic lymph nodal positivity in the ovarian carcinoma: its prognostic significance.

Our study is based on 29 patients with ovarian carcinoma in early stage (IA-IIB) having undergone total abdominal hysterectomy, with bilateral salpingo-oophorectomy, omentectomy, appendectomy and pelvic and paraaortic lymphadenectomy selective and bioptic. Out of the 29 patients 11 were classified I stage and 18 II stage. Within 3 years, out of 10 patients with node metastases, 1 is alive and free of disease, 6 deceased from the tumor and 3 are alive with residual tumor at various stages of invasion. Out of the 19 patients without nodes metastases 14 are alive and free of disease, 4 deceased from the tumor and 1 is alive with residual carcinoma. Survival related to histological type shows no statistically significant differences. Grading III has a survival of 27.6%, while the other two grades have a survival of 70% without significant differences. We can affirm that lymph nodes metastases represent the most reliable marker of high risk patients among the 3 risk factors (grading, histotype and nodes metastases) even if considered on a limited number of patients on the basis of preliminary data so obtained.

Radical vulvectomy and inguinal lymphadenectomy versus inguino-pelvic lymphadenectomy combined with radical vulvectomy and the role of radiotherapy.

We studied 39 patients with stromal invasion exceeding 1 mm. Among them 3 underwent emivulvectomy and 8 simple vulvectomy; all had selective inguinal lymphadenectomy of one side the first and bilaterally the others. 17 women underwent radical vulvectomy and inguinal lymphadenectomy while 11 had radical vulvectomy and inguino-pelvic lymphadenectomy. Out of 21 patients with lymph nodal metastases, 11 had one side inguinal metastases, 2 had a single metastasis, 2 had double metastases, 1 had three metastases and 2 multiple ones. Survival rate decreased from 54.5% to 20.0% when patients had more than 3 monolateral inguinal metastases or bilateral ones, with increase of pelvic lymph nodal metastases; therefore, in those cases, pelvic lymphadenectomy can be associated to inguinal lymphadenectomy or, when the carcinoma is situated in the clitoridis, Bartolino's gland or vagina (the same could be done for melanoma of the vulva). The usefulness of radiotherapy is limited by the small response of vulvar tissue. In a series of 45 patients with clinical diagnosis of inguinal metastases, who could not undergo operation, only therapy, with electron beam therapy (9 meV) associated to inguinal fields (15 meV), had positive influence in 27% of the cases.