Laparoscopic abdominal cerclage after radical vaginal trachelectomy.

BACKGROUND: The incidence of cervical cancer (CC) in Slovenia in 2011 was 13.2 per 100,000 women. The treatment of early stages of invasive cervical carcinoma involves several surgical techniques. In this article the authors would like to present a new combination of two methods which help to preserve fertility and to improve pregnancy outcome. The first procedure, radical vaginal trachelectomy (RVT), begins with laparoscopic pelvic lymphadenectomy. All suspicious lymph nodes are sent to frozen section. If those lymph nodes are negative, the procedure continues vaginally. Almost the entire cervix is removed with parametria and vaginal cuff. Permanent cerclage stitch is applied and covered with vagina on what is left of uterus. Second procedure, laparoscopic abdominal cerclage (LAC), begins with pneumoperitoneum. Mersilene tape is introduced in the abdominal cavity and placed through the visceral peritoneum at the isthmic part of the uterus with a Berci's needle. It is knotted and remains permanently. MATERIALS AND METHODS: For the first procedure all the patients with confirmed cervical carcinoma (FIGO Stage IA1, IA2, and IB1) and with the desire for fertility were recruited. For the second procedure, all the patients after RVT and after miscarriage after 14th week of gestation were recruited. RESULTS: RVT was performed in 15 patients and laparoscopic abdominal cerclage in three of them (21.5%). All three patients achieved pregnancies and after 36th weeks of gestation delivered by cesarean section (100%). CONCLUSIONS: RVT alone is an indication for LAC. Considering its success, LAC should be performed before any miscarriage.

Sertoli - Leydig cell tumor with retiform areas and overgrowth of rhabdomyosarcomatous elements: case report and literature review.

BACKGROUND: Sertoli - Leydig cell tumors (SLCTs) are sex-cord stromal tumors that account less than 0.5 % of primary ovarian neoplasms. They are mostly benign and occur in reproductive age women. Variants with heterologous mesenchymal elements are exceptionaly rare. The usual presentation of SLCTs is with signs of androgen excess as majority of them produce androgens. CASE PRESENTATION: We present a case of a SLCT occurring in a 70 year old woman. Her presenting complaint was abdominal distension and pain. She had no signs of androgen or estrogen excess. Transvaginal ultrasound (TVUS) and CT scan showed a multilocular adnexal tumor and level of CA 125 was raised. A complete cytoreduction was achieved with surgical procedure. Histopathological examination revealed moderately differentiated SLCT with retiform areas and owergrowth of heterologous component in form of embrional rhabdomyosarcoma (RMS). She returned 7 months after the surgery with a large abdominal mass, ascites, right- sided hydronephrosis and massive pulmonary embolism. Due to the widespread disease and her poor general condition, she received only palliative care. She died 15 days after the admission. No autopsy was performed. CONCLUSIONS: Due to the rarity of SLCTs, especially those with retiform areas and heterologous elements, their management remains challenging. There is no firm evidence that adjuvant chemotherapy is effective in improving survival in SLCTs with malignant heterologous elements. Further studies with a higher number of cases and a longer follow-up are needed to better predicting the prognosis and determine the role of chemotherapy in such cases.

Advanced embryonal rhabdomyosarcoma of the uterine cervix: a case report.

BACKGROUND: Primary embryonal rhabdomyosarcoma (RMS) arising from the uterine cervix is a rare and extremely malignant entity. Young women aged 12-26 years are mostly affected. Before the introduction of effective adjuvant chemotherapy, the prognosis of these lesions was poor. CASE: A 16-year-old girl presented with vaginal bleeding. The histological examination revealed embryonal RMS of the uterine cervix. The patient was treated with a combination of surgery, chemotherapy and radiotherapy. The patient was alive and free of disease five years after the operation. CONCLUSION: A combined modality approach to treating RMS using surgery, multidrug chemotherapy, and radiotherapy has significantly improved survival. The medical community should keep in mind that embryonal RMS of the uterine cervix, despite its malignancy and rarity, can be cured if timely and adequate treatment is given.

Choroidal melanoma metastasized to the ovary: case report and review of the literature.

BACKGROUND: Malignant melanoma metastases to the female genital tract in only 2.5% of cases. Melanoma is characterized by clinical variability and unpredictable biological behavior with long remissions and relapses that develop rapidly. CASE AND REVIEW: A 57-year-old woman was admitted for hypogastric pain and weight loss. She had presented enucleation of the right eye six years before for malignant choroid melanoma. Gynaecological examination revealed enlarged ovaries. Bilateral salpingo-oophorectomy, hysterectomy, and omentectomy were performed. Final pathology diagnosed a choroidal metastatic melanoma (CMM). The patient died seven months later. Only seven cases of CMM have been reported in the literature. Patients affected by CMM ranged in age from 38 to 83 years (median 51.2 years), the time to relapse ranged from 3-25 years (median 51.2 years), the size of the cysts ranged from 4-17 cm (median 9.7 cm) and the survival period ranged from 2-14 months (median 8.1 months). CONCLUSION: Malignant melanoma is misdiagnosed because of lack of discriminatory symptoms, increased tumor markers, characteristic imaging findings and the capacity to mimic other tumors. Today CMM still represents a challenge for gynecologic oncologists.

Giant pelvic retroperitoneal liposarcoma: case report.

BACKGROUND: Pelvic retroperitoneal liposarcomas are rare tumors of mesenchymal origin. We present a case of a giant pelvic well-differentiated liposarcoma of the retroperitoneum in a woman, presenting with a large abdominal mass. CASE: A 62-year-old woman presented with a rapid abdominal enlargement. Pelvic examination revealed a huge mass occupying the whole pelvis and part of the right abdomen. At surgery, the pelvic organs were displaced to the right side by a retroperitoneal mass that marginally involved the part of the posterior abdominal wall, left parietal peritoneum of the diaphragm, left colic flexure and the left adnexa. The huge mass, uterus, and both adnexa were removed; hemicolectomy and latero-lateral anastomosis were carried out. No adjuvant irradiation was given. The patient is alive and free of disease five years after the operation. CONCLUSION: The gynecologist should consider retroperitoneal liposarcoma in the differential diagnosis of large pelvic or abdominal masses.

Amelanotic malignant melanoma of the uterine cervix with ten-year follow-up.

BACKGROUND: Malignant melanoma (MM) accounts for 3% of cancers that affect women and results in less than 1% of cancer deaths. It is characterized by clinical variability and unpredictable biological behavior. Fewer than ten cases of amelanotic MM (AMM) have been reported in literature. CASE: A 61-year-old woman was admitted for vaginal spotting. A huge, soft cervix with an exophytic lesion was biopsied. A clear cell carcinoma, FIGO Stage IB1, was diagnosed and radically treated. The final pathology showed an AMM of the cervix positive for PAS and HMB 45. The patient is clinically free of disease ten years postoperatively. CONCLUSION: Malignant melanoma of the cervix is often misdiagnosed because of non discriminatory features and the capacity to mimic other tumors. Malignant melanoma of the cervix needs to be diagnosed as quickly as possible because a timely therapy and a long and careful follow-up might result in better survival.

Use of lysophosphatidic acid in the management of benign and malignant ovarian tumors.

OBJECTIVE: To establish whether LPA determination improves the differentiation of benign from malignant ovarian tumors. METHODS: Total LPA and LPA species in the serum were determined using a novel method in 142 patients with ultrasound (US) suspecious ovarian tumors and in 78 healthy women. All women underwent determination of CA125 in the serum, a vaginal US examination and morphology scoring of the tumor. RESULTS: The levels of total LPA and its species in women with ovarian tumors were significantly higher from those in healthy women (p < 0.001). No significant difference was found in the levels of total LPA or any of its species between the women with benign and those with malignant ovarian tumors. CONCLUSIONS: Determination of serum LPA would be an appropriate test for ovarian tumor presence, especially in women of reproductive age. The method however does not differentiate benign from malignant ovarian tumors.

[Current surgical management in ovarian cancer recurrences]. / Attuale management chirurgico delle recidive di carcinoma ovarico.

Ovarian cancer is a tumor with a high trend of recurrence and this occurrence consistently increases the difficulty of the patient cure and reduces the efficacy of current treatments. The role of surgery in persistent or recurrent ovarian cancer is controversial and the type of surgery can be different according to the different stages and invasion of tumor; it can be a debulking surgery followed by chemotherapy (to eradicate the most part of ovarian cancer, leaving a minimal tumoral residue), an interval surgery (for advanced ovarian cancer stage in previously operated patients, followed by 2 or 3 inductive chemotherapy cycles and subsequently a cytoreductive redo surgery) and a cytoreductive secondary surgery, after optimal primary surgical treatment and minimal tumoral recurrence. In some cases it is possible either to perform a debulking surgery during a primary (after the conclusion of primary treatment) or a salvage or palliative surgery (to improve, after an acceptable time period, clinical symptoms in patients with progressive cancer or resistant to treatments). The aims of surgical therapy, to be performed in a patient with ovarian cancer relapse, are to reduce, as much as possible, the tumour size, to increase the quality of life and to increase the survival time; in this review different surgical techniques to be carried out in each case, selected for disease staging, for tumour cells kinetic and for surgical goals, are discussed.

Herpes simplex genitalis type 2: our experiences.

OBJECTIVE: To review the recent research in genital HSV infection and to pay attention to this problem in Slovene population. METHODS: Review of all papers in the field on Medline 1994-98. A descriptive retrospective analysis of symptoms, seroprevalence, treatment, complications and follow-up of 49 HSV-1 and HSV-2 seropositive patients. RESULTS: Five patients with overt genital herpes were HSV-1 seropositive, and four were HSV-1 and HSV-2 seropositive. One patient had extragenital spread and HSV proctitis. Treatment consisted of 1 gr daily dose of Acyclovir (ACV) in combination with topical ACV for two to three weeks. Recurrences were intermittently treated in three patients and one started suppressive treatment. Three pregnancies terminated vaginally with healthy babies. CONCLUSIONS: According to literature overview and our experiences, more attention should be paid on revealing mild forms of genital herpes in order to diminish the spread of infection and its consequences.

Pretreatment evaluation of adnexal tumors predicting ovarian cancer.

Kobal B, Rakar S, Ribic-Pucelj M, Tomazevie T, Zaletel-Kragelj L. Pretreatment evaluation of adnexal tumors predicting ovarian cancer. The objective of this study was to determine the ability of tumor marker assessment, gray-scale transvaginal with color Doppler ultrasonography to predict ovarian malignancy. One hundred thirty-four subjects with ovarian masses who entered the study prospectively underwent pelvic examination, tumor marker assessment and gray-scale transvaginal with color flow Doppler ultrasonography preoperatively. Malignancy predictors were statistically evaluated with stepwise multiple logistic regression, and the scores from the model were transformed to probability for having a malignant disease. The presence of neovascularization, intracystic papillary projections, elevated serum CA 125, and age over 45 years were significant predictors for malignancy. Positive predictive value (PPV) for the regression model was 89.0%, and negative predictive value (NPV) was 96.8%. Probability for malignancy ranged from 0.004 to 0.991 depending on which covariates were included. Logistic regression analysis of pretreatment diagnostic gray-scale and color Doppler ultrasonographic characteristics, together with CA 125 enabled a creation of probability assessment scale for individual estimation of ovarian mass, which may contribute to final clinical decision.

[Characteristics of patients with laparoscopically verified pelvic inflammation]. / Obiljezja bolesnica s laparoskopski utvrdenom pelvicnom upalom.

Comparing the characteristics of the two groups young women: one with laparoscopically confirmed pelvic inflammatory disease (PID) and the other with no PID (control group) but corresponding to the first group by age, marital status and number of pregnancies, it has been found that the patients with PID are below 25 years of age, have a lower degree of education (p less than 0.05), and 25.5% of them do not use any contraceptive method (p less than 0.01). It has also been observed that in their gynecologic history they mention an episode of lower abdominal pain (p less than 0.01). A further comparison of this finding with laparoscopically confirmed adnexal changes has shown that in 50% of the study group patients there exist sequelae of an earlier PID episode (asymptomatic salpingitis). The results obtained point to the need for carefully connecting the characteristics of the population regarding the risk of PID and the minimal clinical symptoms in diagnosing PID.

Laparoscopic treatment of acute adnexitis; one step forward.

Supplementary laparoscopic method accompanying antibiotic treatment in 8 patients with acute PID (ALT Group) was compared to the group of 28 patients with acute PID, diagnosed laparoscopically and treated medically (MLT Group). Rapid subjective improvement of general status in which main symptoms of acute PID disappeared, the absence of early PID complications (p less than 0.01), shorter hospital treatment (p less than 0.05) and the absence of recurrence (p less than 0.01) in the first 6 months are the major advantages of the supplementary laparoscopic treatment of acute adnexitis found in preliminary results of the present study. It seems that supplementary laparoscopic procedures might be more efficient than medical treatment alone.