Bilateral breast metastasis of ovarian carcinoma.

Primary breast carcinoma is the most common malignancy in women, however, metastatic breast carcinoma is rarely seen in clinical practice. It has been reported that lymphoma-leukemia, melanoma and sarcomas, the most common primary malignancies, can metastasize to the breast. On the other hand, ovarian carcinoma and other gynecologic cancers rarely develop into breast metastasis. However, the incidence of breast metastasis arising from ovarian carcinoma might be increasing as a result of prolongation in survival and improvement in treatment modalities. Bilateral breast metastasis originating from an ovarian carcinoma is an extremely rare clinico-pathological situation. In our literature review we found just nine cases of bilateral breast metastasis from primary ovarian carcinoma. In this study, the mean age was 46 years (range 16-68). Mean interval from initial diagnosis of ovarian carcinoma to bilateral breast metastases was 22 months (range 11-24) and mean survival was 12 (range 5-27) months after the diagnosis of breast metastasis. Serous papillary adenocarcinoma was the predominant histological subtype. Interestingly, five of the nine (56%) cases reported were from Turkey. This interesting observation can be explained by a genetic predisposition, but it requires further research. In conclusion, although it is a rare entity, breast metastasis should not be ruled out in patients with a history of ovarian carcinoma, if patients present with any symptoms of breast diseases.

Ovarian transposition for the preservation of ovarian function in young patients with cervical carcinoma.

Radiotherapy with or without surgery for the treatment of pelvic malignancies irreversibly destroys the hormonal activity and reproductive capacity of ovaries in young women. On the other hand, menopausal symptoms associated with estrogen deficiency is an important contributor to the poor quality of life scores in gynecologic cancer survivors. Transposing of the ovaries into the paracolic gutters (ovarian transposition) was described in 1958 with the aim of protecting gonadal functions in reproductive-aged women treated by pelvic radiotherapy and/or surgery. Although the laparatomic approach has been used as a parallel to development in endoscopic surgery, today it is generally performed laparoscopically. However, there is ongoing debate about the effectiveness of ovarian tranposition with respect to protecting gonadal functions. Moreover, metastasis to the transposed ovaries and port sites is another concern about this procedure. In this short review, indications, techniques and functional outcomes of ovarian transposition have been summarized.

New surgical approaches for the management of cervical carcinoma.

Cervical carcinoma remains an important health problem in both developed and developing countries even though population-based screening programs are widely available. The classical surgical management of early-stage cervical carcinoma, known as radical hysterectomy (RH), was first described by Wertheim more than one hundred years ago and was then modified and re-popularized by Meigs in 1950s. The surgical principles of this operation have undergone only minor modifications and remain the basis for the surgical approach utilized by gynecologic oncologists today. However, some recent studies have questioned the role of RH due to a high rate of postoperative complications involving the pelvic autonomic nerve system and poor oncological outcomes despite postoperative adjuvant chemoradiation. During the last 2 decades, new surgical operations (radical vaginal trachelectomy, nerve-sparing hysterectomy, total mesometrial resection, laterally extended endopelvic resection, laparoscopic assisted radical vaginal hysterectomy, laparoscopic lumbo-aortic lymph node dissection, and laparoscopic pelvic exenteration) have been proposed for the management of both early- and late-stage cervical carcinoma. In this manuscript, some technical details and oncological outcomes of these new surgical approaches are summarized.

Labor induction at term: a comparison of the effects of 50 microg and 25 microg vaginal misoprostol.

PURPOSE OF INVESTIGATION: To compare the effects of 50 microg of vaginal misoprostol with 25 microg for labor induction at term. METHODS: One hundred and forty-seven pregnant women with indications for labor induction and cervical Bishop's score of < or = 6 were randomly assigned to receive either 50 microg (n = 74) or 25 microg (n = 73) of vaginal misoprostol every four hours until either a Bishop's score of > or = 8 or adequate uterine contraction frequency had been achieved. Induction-to-vaginal-delivery time was considered the primary outcome measure. RESULTS: Mean induction-to-vaginal-delivery time was significantly shorter in the 50-microg group than in the 25-microg group (526 +/- 141 min vs 745 +/- 218 min, respectively); oxytocin was administered to 65.8% of the patients in the 25-microg group and to 35.1% in the 50-microg group (p < .05). The incidence of tachysystole was significantly higher in the 50-microg group than in the 25-microg group (12% vs 2.7%, p < .05). We found no statistically significant difference between the two groups with respect to the rate of primary cesarean section, incidence of hyperstimulation syndrome, or neonatal outcome (p > .05). CONCLUSION: Fifty micrograms of vaginally administered misoprostol is an effective and inexpensive means of inducing labor at term. Uterine tachysystole may be associated more frequently with a 50-microg dose of vaginal misoprostol than with a 25-microg dose. Clinicians must accurately document the frequency and intensity of uterine contractions before every 50-microg dose of misoprostol is administered.

Thecoma associated with pregnancy: a case report.

Ovarian thecoma, which belongs to the group of sex-cord stromal tumors, is a relatively rare neoplasm. In this report we present a pregnant woman with a solid ovarian mass diagnosed during pregnancy and operated on at the 19th gestational week. At surgical exploration, torsion of the ovarian tumor was observed together with ascites and unilateral salpingo-oophorectomy was performed. Pathological examination revealed a luteinized thecoma. After the surgery, the pregnancy continued uneventfully until term.

Impact of morbid obesity in surgical management of endometrial cancer: surgical morbidity, clinical and pathological aspects.

OBJECTIVE: To evaluate the effect of body mass index (BMI) on clinical, surgical, pathologic features, and surgical morbidity in the management of patients with endometrial cancer. MATERIALS & METHODS: All endometrial cancer patients who were surgically treated in our institution between January 1, 2003 and January 1, 2006 were eligible for the study. Forty-two out of 60 patients were included in the analysis from our cancer database. The patients were divided into three groups: BMI < 30, BMI 30-40, BMI > 40. Statistical analysis was performed by SPSS for Windows (version 11; SPSS, Inc., Chicago, IL). RESULTS: Lymphadenectomy as part of surgical staging was performed in 90.5% of all patients. Although patients with a BMI > 40 were less likely to have positive lymph vascular space invasion (LVSI) (p = 0.042), chance of deep myometrial invasion and positive lymph nodes (18%) were the same as for patients with a BMI < 30. Patients with a BMI > 40 had statistically longer operating times when compared to patients with a BMI < 40 (p = 0.039). Wound separation rate was statistically higher in the morbidly obese patients (p = 0.01). Average number of lymph nodes removed, hospital days, intraoperative and overall postoperative complication rates did not differ among the three groups (p > 0.05). CONCLUSIONS: This study confirms that comprehensive surgical staging can be performed adequately and safely in obese and morbidly obese endometrial cancer patients with no difference in length of hospital stay, intraoperative or postoperative complications. As a result adjuvant treatment of morbidly obese patients can be planned accordingly preventing under or over treatment.

Expression of survivin, PTEN and p27 in normal, hyperplastic, and carcinomatous endometrium.

We aimed to investigate if expressions of survivin and p27 proteins are involved in the development of endometrioid carcinoma, along with whether there are any correlations between these proteins and loss of wild-type PTEN that is found in up to 80% of endometrial carcinomas. We also studied their correlations with classical prognostic factors and survival in endometrial carcinoma. To our knowledge, this is the first time survivin expression is investigated in endometrial hyperplasia along with endometrioid adenocarcinoma. For immunohistochemical analysis, 29 endometrioid adenocarcinoma, 38 endometrial hyperplasia, and 10 proliferative endometrium tissue samples were selected in the pathology archives. Staining of cells was scored as +2 if >50%, +1 if <50%, and negative if none were stained positive. Survivin expression increased from proliferative to hyperplasia to carcinoma cases. PTEN and p27 expressions decreased in hyperplasia and carcinoma cases with respect to proliferative endometrium. All these differences were statistically significant (P < 0.05). PTEN positively correlated to p27 (P < 0.05); however, neither was correlated with survivin. None of these genes were correlated with classical prognostic factors such as grade and myometrial invasion in endometrioid adenocarcinoma. However, mean survival was statistically significantly higher in PTEN-positive cases (46.6 vs 16.4 months) (P < 0.05). Survivin overexpression might be one of the important mechanisms in the development of endometrioid adenocarcinoma along with lost or decreased activity of PTEN and p27. However, survivin seems to exert its role in ways different from those of PTEN or p27 in the development of endometrioid adenocarcinoma. These findings on the role of survivin in endometrioid adenocarcinoma should be confirmed and the pathways through which survivin acts in endometrioid adenocarcinoma studied further with a larger sample size.

Primary leiomyoma of the ovary in a young woman: literature review and report of a case.

Ovarian leiomyoma is a rare tumor. We present a case of ovarian leiomyoma in a 32-year-old virgin with the complaint of dysmenorrhea for six months. On magnetic resonance imaging, a 6 cm x 4 cm mass in the left ovary exhibiting hypointense signals on both T1-weighted and T2-weighted images was initially considered to be fibroma and/or thecoma. However, after surgery the pathological diagnosis of the removed tumor was leiomyoma of the left ovary. The literature on this rare tumor was also reviewed.

Gastrointestinal stromal tumors presenting as pelvic masses: report of two cases.

We present two cases of gastrointestinal stromal tumors (GISTs) that presented as pelvic masses. These tumors can present diagnostic problems and they may be difficult to discover preoperatively. GISTs are neoplasms that can be diagnosed utilizing immunohistochemistry, especially detecting CD117 (c-kit) reactivity along with associated histological features. GISTs, should be considered in the differential diagnosis of ovarian tumors especially when imaging studies and rectovaginal examination findings are inconclusive and vague. Histologic diagnosis of these tumors are important considering the efficacy of tyrosine kinase inhibitor therapy after surgery in such cases.

Expression of cyclin H in normal and cancerous endometrium, its correlation with other cyclins, and association with clinicopathologic parameters.

Cyclins are known as regulatory proteins in cell cycle. Cyclin H is a part of cyclin H/Cdk7/Mat1 complex, which is necessary for cellular proliferation. This study was designed to investigate the correlation of cyclin H expression with tumorigenesis of the endometrium and clinicopathologic variables. Immunohistochemical staining using labeled streptavidin-biotin complex was performed on formalin-fixed, paraffin-embedded endometrial tissues of the proliferative, hyperplastic, and carcinomatous types. Immunostaining for cyclins A, B1, D1, D3, E, H, and cyclin dependent kinase 2 were evaluated. The expression of cyclins A, D1, D3, and H in hyperplasia was significantly more frequent than those of proliferative phase and less than those of endometrioid adenocarcinoma. The expression of cyclin H was correlated with lymphvascular space invasion and clinical stage in carcinoma but not with myometrial invasion, lymph node metastasis, and menopause status. The expression of cyclin H could be involved in the transformation of the endometrium into malignancy and might be a marker for more proliferative and malignant features. It might be one of the biomarkers for determining proliferative activity in endometrial hyperplasia and endometrioid adenocarcinoma.

Seronegative systemic lupus erythematosus: etiology of nephrotic syndrome and acute renal failure in early postpartum period.

Systemic lupus erythematosus (SLE) is an autoimmune syndrome that occurs most commonly in women during their reproductive years. Nephritis is known to be one of the most serious complications of SLE. Lupus nephropathy is frequently associated with ANA and anti-dsDNA antibodies. Rarely, serological markers may be initially absent, and in many cases, they become positive after sometime. We present a 28-year old, otherwise healthy female who admitted to our clinic with edema, hypertension, proteinuria and acute renal failure following her fourth delivery. Serum immunological markers were negative and renal biopsy showed histopathological changes consistent with systemic lupus erythematosus as the etiology of nephrotic syndrome. A dramatic therapeutic response was achieved by pulse steroid and cyclophosphamide treatment following oral steroid therapy. In women with new onset nephrotic syndrome or renal function deterioration in postpartum period, even if the patient is asymptomatic or seronegative, it is crucial to exclude SLE for a rapid diagnosis and prompt treatment in the case of lupus nephritis. Renal biopsy is of diagnostic importance in such cases in which there is no other clinical, biochemical and serological evidence of the disease.

Pelvic retroperitoneal paraganglioma mimicking an ovarian mass.

A 75-year-old hypertensive woman was referred with ultrasound findings of a 40 x 35 mm semi-solid right adnexal mass and right hydroureteronephrosis. She complained of headache and right-sided back pain. Computed tomography demonstrated a cystic adnexal mass that did not appear to originate from the right ovary and grade 2 hydroureteronephrosis. Magnetic resonance imaging indicated that the mass originated from the right ovary. Tumor markers were in the normal range. Exploratory laparotomy was performed to determine the origin of the lesion, and revealed a retroperitoneal mass obstructing the right ureter. The mass was completely removed and and the histopathologic diagnosis was paraganglioma.

Primary ovarian leiomyosarcoma: a case report.

Primary ovarian leiomyosarcomas are extremely rare tumors that comprise less than 0.1% of all ovarian malignancies. We present a case of 62-year-old postmenopausal woman with a slightly enlarged right ovary and a Color Doppler sonography resistance index (RI) measuring 0.54. The patient, after being managed with surgery alone, is alive after 14 months without any evidence of disease. This is an unusual case in that primary ovarian leiomyosarcoma was diagnosed in the setting of a slightly enlarged irregular postmenopausal ovary with a concomitant intermediate RI value on color flow Doppler evaluation. A high index of suspicion may help prevent delay in the diagnosis of this rare neoplasm.

HPV and p53 expression in epithelial ovarian carcinoma.

OBJECTIVES: Human papillomavirus is the causal factor for cervical cancer. However, the role of HPV infection in ovarian cancer is unclear. This study aimed to determine the presence of human papillomavirus (HPV) in ovarian cancer tissues along with the expression of tumor suppressor gene p53. We also investigated any possible association of HPV with p53 gene mutations in ovarian carcinoma. METHODS: Archived human ovarian cancer tissues (n = 40 cases of epithelial ovarian cancer) embedded in paraffin blocks were used. Controls were 32 non-malignant ovarian tumor tissue blocks. In situ hybridization (ISH) and immunohistochemistry (IHC) were used to detect the presence of HPV and p53 expression, respectively. RESULTS: Of the total, 37.5% (n = 15) of malignant and 28.1% (n = 9) of benign ovarian tumors were positive for HPV (OR: 1.5 CI: 0.5-4.1, p = 0.4). The difference was not statistically significant. However, p53 was detected in 72.5% (n = 29) of malignant cases compared to 37.5% (n = 12) of benign cases (OR: 4.3 CI: 1.6-11.9, p = 0.003). Furthermore, a positive correlation between HPV and p53 expressions in ovarian cancer tissue samples was detected (r = 0.47, p = 0.001). CONCLUSIONS: HPV does not seem to be a major component in the development of ovarian carcinoma, nevertheless HPV positivity seems to contribute to the pathogenesis in at least some ovarian carcinoma cases by way of interaction with tumor suppressor p53.

Well-differentiated papillary mesothelioma complicating endometrial carcinoma: a case report.

We present a case of well-differentiated papillary mesothelioma discovered during staging surgery for endometrial carcinoma in a 50-year-old postmenopausal woman. In case of simultaneous well-differentiated papillary mesothelioma (WDPM) and endometrial carcinoma, the surgeon may be mistaken by considering peritoneal implants as tumor metastasis. This situation may result in overtreatment of the patient. Thus a thorough pathologic examination of the specimens taking care not to miss any areas of invasion, and utilizing immunohistochemical analysis when necessary are important to avoid such mistakes. To our knowledge this is the first report of the simultaneous occurrence of endometrial carcinoma in conjunction with diffuse WDPM of the peritoneum.

Pregnancy during hemodialysis: perinatal outcome in our cases.

The perinatal outcome of patients undergoing chronic hemodialysis has been improved in recent years. In this report we review the treatment and outcome of seven pregnancies in women undergoing chronic hemodialysis before and during pregnancy between 2000 and 2002. The hemodialysis schedule was increased from 4 hours twice weekly to 4 hours four to six times weekly. Hemodialysis was performed using a high-flux dialyzer with volume-controlled ultrafiltration. The patients were followed in close collaboration between the obstetrician and the nephrologist. Monitoring of fetal well-being was started after 24 weeks' gestation, using cardiotocography by a nonstress test twice weekly and by weekly Doppler flow measurements. All patients underwent uterine contraction monitoring immediately after the dialysis. The mean gestational age at delivery was 32 weeks (range, 26 to 36 weeks). The causes of preterm delivery were premature contractions, premature rupture of membranes, preeclampsia, and intrauterine growth restriction. The outcomes were two pregnancies complicated by polyhydramnios and six pregnancies, that resulted in live births, all of whom survived. There was one neonatal death. The mean newborn birthweight was 1400 g (range, 420 to 2640 g) and the 1- and 5-minute Apgar scores ranged from 2/8 and 4/10, respectively one infant at 29-weeks gestation experienced respiratory distress syndrome but did well after 12 days. Cesarean section was performed in four pregnancies. The mothers were discharged on postoperative days 3 to 5. It is well known that the management of pregnant patients undergoing chronic hemodialysis is difficult. However, advances in dialysis, obstetrics, and neonatal care have improved the outcomes.

Management of advanced-stage primary carcinoma of the fallopian tube: case report and literature review.

Primary carcinoma of the fallopian tube is a very unusual gynecologic malignancy that accounts for less than 1% of all malignancies of the female genitalia. A 55-year-old, gravida 7, para 3 woman presented with no gynecologic complaints other than backache. TVS demonstrated a 35 x 25 mm heterogeneous mass that was not clearly separated from the left ovary, and another 31 x 14 mm cystic septated lesion in the left ovary region. Pelvic MRI demonstrated a 35 x 35 x 20 mm left adnexal mass that enhanced with contrast and a neighboring tubular-cystic mass. Upper and lower gastrointestinal endoscopy revealed no malignancy. Serum CA 125-level was merkedly elevated at 369 U/ml (normal < 35 U/ml). Laparotomy revealed left hydrosalpinx and a papillary-fimbrial mass. Pelvic lymph node metastases were observed. Frozen-section analysis identified the mass as a serous adenocarcinoma. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, pelvic and para-aortic lymph node dissection, and peritoneal washing were performed. The definitive histopathological diagnosis was primary serous adenocarcinoma of the fallopian tube with six of 25 lymph node biopsies showing metastasis. Six cycles of paclitaxel (175 mg/m2) plus cisplatin (75 mg/m2) combinatin chemotherapy were administered with 3-week intervals between cycles. Second-look laparotomy was performed; there was no evidence of disease. At the time of writing 12 months after the second-look laparotomy, she was still disease-free.

Primary carcinoid tumor of the ovary: a case report.

Primary ovarian carcinoid tumors are rare. A 47-year-old woman presented to our emergency room with lower abdominal pain. Physical examination, pelvic ultrasonographic evaluation and abdominal computed tomography revealed a 10-cm mass in the right ovary containing cystic and solid components, as well as calcifications typical of a dermoid cyst. At laparotomy, a smooth-surfaced, firm and mobile right adnexal mass with solid and cystic portions was detected. Initially, right salpingo-oophorectomy was performed. Frozen-section examination identified the mass as a sex cord stromal tumor containing a mature cystic teratoma. Based on this finding, total abdominal hysterectomy, left salpingo-oophorectomy, omentectomy, appendectomy were performed, and the pelvic-paraaortic lymph nodes were also removed. All histological findings in the right ovary were similar to the features of cystic teratoma and trabecular carcinoid tumor. Examination of the resected lymphatic, omental, and appendiceal tissue indicated no tumoral invasion. The diagnosis was ovarian carcinoid Stage IA. Serum testing post-surgery revealed that the levels of cancer antigen (CA) 19-9 and CA125 were 18.5 u/ml and 10.5 u/ml, respectively. The patient was discharged on postoperative day 5. The report describes the clinicopathologic and immunohistochemical features of a primary ovarian carcinoid that contained a mature cystic teratoma.