Hysteroscopic diagnosis of uterine sarcomas at the Department of Gynaecology, Sant Joan de Déu University Hospital.

Uterine sarcomas are rare and the clinical diagnosis of sarcoma is difficult. Diagnostic and surgical hysteroscopy is a minimally invasive outpatient procedure that makes an accurate diagnosis of malignant intrauterine pathology and could play a role in the diagnosis of the uterine sarcomas. Uterine sarcomas diagnosed at the Department of Gynecology of Sant Joan University Hospital by hysteroscopy between January 2004 and August 2010 are described. In this period 2,441 hysteroscopies were performed; a total of 67 adenocarcinomas of the endometrium and five sarcomas were diagnosed by hysteroscopy. The data are presented with a review of the literature, focusing on the diagnostic value of hysteroscopy in these tumors.

Granulosa cell tumor and endometrial cancer: a case report and review of the literature.

Granulosa cell tumors (GCTs) of the ovary are an uncommon type of ovarian cancer, representing only 2-5%. Frequently, their tumoral cells present some features of normal granulosa cells, like hormonal production. As a consequence, this neoplasia can be diagnosed either by common ovarian cancer symptoms or endometrial pathologies due to an estrogenic effect. Symptoms caused by estrogen production can also give rise to different clinical manifestations depending on whether they appear in postmenopausal or young women. In the case we present below, a patient was referred for presenting postmenopausal bleeding of one year's duration. Once endometrial cancer was diagnosed and subsequently staged, an ovarian mass was detected. We report an atypical case of ovarian cancer with the aim of reviewing the clinical features of GCT, as well as its prognosis, treatment and follow-up recommendations, according to the available literature.

Hysteroscopic diagnosis of a high-grade endometrial sarcoma in a 41-year-old woman.

Endometrial stromal sarcomas originate in the endometrial cavity. These tumors represent between 15-27.9% of uterine sarcomas. We present the case of a 41-year-old woman who underwent surgical hysteroscopy for metrorrhagia over a period of one month who had an intrauterine polypoid mass detected by ultrasonography. Histologic analysis of the polypoid mass removed by hysteroscopy was a high-grade endometrial stromal sarcoma of the uterus. The description of this case provides an opportunity to review the literature on uterine sarcomas diagnosed by surgical hysteroscopy.

Predictive factors for the detection of CIN II-III in the follow-up of women with CIN I.

PURPOSE OF INVESTIGATION: To determine which factors may increase the risk that women diagnosed with CIN I may later develop CIN II-III. METHODS: A prospective study of 174 women with a grade 1 intraepithelial lesion (CIN I) confirmed by biopsy, with a follow-up time of at least one year. The following factors were studied: age, HPV infection, HPV infection by a high-risk genotype, the HPV genotypes involved, coinfection by several HPV genotypes and duration of follow-up. These factors were correlated with later detection of CIN II-III by biopsy during follow-up. Statistical analysis was performed using SPSS. RESULTS: CIN II-III was detected at the follow-up in 24 of 174 women included in the study (13.7%), in four cases by colposcopically directed biopsy and in 20 by LLETZ. Correlation of the factors studied with the incidence of CIN II-III in this group showed that the only statistically significant factors were overall HPV infection and HPV infection by genotypes 31 and 70 (Chi-square and Fisher's test, p < 0.05, respectively), while the duration of follow-up came close to statistical significance (Student's test, p = 0.052). CONCLUSION: HPV infection and duration of follow-up are predictive factors for the detection of CIN II-III in follow-up care for women with CIN I.

Cesárea anterior por desproporción pelvi-fetal y gestación cronológicamente prolongada / Prior cesarean section due to fetopelvic disproportion and prolonged pregnancy

Objetivos Valoración de la vía y el modo de finalización de la segunda gestación en pacientes con cesárea anterior (CA) por desproporción pelvi-fetal (DPF).Material y métodos Hemos revisado 102 pacientes con CA y gestación superior a 40 semanas, en las que se realiza inducción de parto (54 casos) o cesárea electiva (48 casos) y 98 pacientes con CA por DPF que inician trabajo de parto espontáneamente. Resultados Gestación cronológicamente prolongada (GCP) con CA por DPF: el 51% de los casos finaliza la gestación con cesárea electiva y el 49% con inducción de parto. De éstos, el 65% acaba con cesárea durante el trabajo de parto y el 35% con parto vaginal. Resultados Inducción según motivo de CA: CA por DPF, el 35% acaba en parto vaginal versus el 65%, que acaba en cesárea durante trabajo de parto. En CA por inducción fallida, el 45 versus el 55%. En CA por presentación de nalgas, el 28 versus el 72%. En CA por riesgo de pérdida de bienestar fetal, el 66% versus el 33%, y en CA por otras causas, el 62 versus el 38%. Estas diferencias son estadísticamente significativas. Resultados De las CA por DFP que inician trabajo de parto espontáneamente, el 36% acaba en cesárea y el 64% en parto vaginal. En estos resultados hay diferencias significativas con inducciones por GCP en CA con DPF. Resultados La edad gestacional media del inicio de parto espontáneo es de 39,63 semanas, concentrándose el 81% del total entre 39–41 semanas. Conclusiones Consideramos indicado conducta expectante en gestantes con CA por DPF hasta la semana 41 y, en este momento, decidir cesárea electiva o inducción de parto (AU)

Objectives To evaluate the route and mode of delivery in second pregnancies in patients with a prior cesarean section (PCS) due to fetoplevic disproportion (FPD).Material and methods We reviewed 102 patients with a PCS and pregnancy over 40 weeks, in which labor was induced (54 patients) or elective cesarean was performed (48 patients) and 98 patients with PCS due to FPD who started labor spontaneously. Results Among women with prolonged pregnancy and PCS due to FPD, elective cesarean section was performed in 51% and labor was induced in 49%. Of these, cesarean section was performed during labor in 65% and delivery was through the vaginal route in 35%. Among women with labor induction, the results, depending on the cause of the PCS, were as follows: in women with PCS due to FPD, 35% delivered through the vaginal route versus 65% who underwent cesarean section during labor; in PCS due to failed induction, 45% versus 55%; in PCS because of breech presentation, 28% vs 72%; in PCS because of non-reassuring fetal heart rate, 66% versus 33%; and in PC because of other causes, 62% versus 38%. These differences were statistically significant. In women with PCS due to FPD who started labor spontaneously, 36% underwent cesarean section and 64% had a vaginal birth. Significant differences were found with labor induction because of prolonged pregnancy with PCS due to FPD. The mean gestational age at onset of spontaneous labor was 39.63 weeks, with 81% of the total starting at 39–41 weeks. Conclusions We recommend expectant management in patients with PCS because of FPD until 41 weeks, after which time, the decision to induce labor or perform an elective cesarean section should be made (AU)

Villoglandular papillary adenocarcinoma of the uterine cervix: a case report and literature review.

Villoglandular papillary adenocarcinoma is an infrequent form of well differentiated cervical papillary adenocarcinoma that has recently been described. It usually affects young women and is distinguished from other adenocarcinomas by its generally good prognosis, since it infrequently invades the lymphovascular space. We present a case of villoglandular papillary adenocarcinoma in a 28-year-old woman presenting risk factors for developing it: use of oral contraceptives, tobacco use, and infection with human papillomavirus types 16 and 33. The presentation of this case provides an opportunity to review the literature on the diagnosis and treatment of villoglandular papillary adenocarcinoma, and the factors that may influence the prognosis of women diagnosed with this histological type of cervical cancer.

Factors modulating circulation of hematopoietic progenitor cells in cord blood and neonates.

BACKGROUND: Hematopoietic progenitor cells (HPC) circulate at high levels at birth and disappear rapidly afterwards, but the underlying mechanism it is not known. The aim of this study was to assess circulating HPC in cord blood at different gestational ages and shortly after birth and concomitantly study the biologic markers involved in this phenomenon. METHODS: All samples were analyzed for CD34(+) cells, colony-forming units (CFU) and cytokines. RESULTS: The results obtained confirmed a slight decrease in HPC concentration during the late stage of fetal life (R(2)=0.41). After birth, CD34(+) cells showed a rapid decline from circulation: 25+/-29% at 3 h, 51+/-42% at 12 h and 80+/-48% at 60 h. CFU cleared following a similar pattern. Cord plasma showed higher concentrations of stem cell factor (SCF), fetal liver tyrosine kinase 3-ligand (FLT3l), erythrpoietin (EPO), granulocyte colony-stimulating factor (G-CSF) and interleukin-11 (IL-11) compared with an adult control. Interestingly, the EPO concentration in newborn plasma correlated with the kinetics of HPC decline after birth. Moreover, we observed an up-regulation of l-selectin and a down-regulation of CXCR4 expression in CD34(+) cells 3 h after birth. DISCUSSION: These data combined suggest that an active homing process results in the clearance of HPC from the circulation immediately after birth.

Stage 1B cervical cancer in a pregnant woman at 25 weeks of gestation.

Cervical cancer associated with pregnancy is rare (0.05%), although it is the most frequently diagnosed malignancy in pregnant women. We present the case of a 28-year-old woman at 25 weeks of gestation diagnosed with Stage 1B cervical cancer. Treatment was delayed until fetal maturity, and an elective cesarean section was performed at 33 weeks' gestation, followed by a total hysterectomy preserving the ovaries, and a pelvic lymphadenectomy. A review of the literature on the treatment of cervical cancer during pregnancy relevant to the case described is also presented.

Comparison of conization and limited excision of the transformation zone (LETZ) in the treatment of squamous intraepithelial lesions (SIL) of the uterine cervix.

OBJECTIVE: To compare the treatment of squamous intraepithelial lesions of the uterine cervix using conization with limited excision of the transformation zone (LETZ). MATERIAL AND METHODS: A retrospective study of 285 women who received surgical treatment for cervical SIL between 2003 and 2006 was carried out. Prior to treatment, all the women underwent cervicovaginal cytology, colposcopy, and HPV testing. The women whose histology showed the presence of high-grade SIL were then divided into two groups for purposes of comparison: those treated by conization, and those treated by LETZ. RESULTS: In group 1 (treatment by conization), 92 women met the selection criteria, and in group 2 (treatment by LETZ) 33 women met the selection criteria. Histology results showed high-grade SIL involvement of the-cone biopsy surgical margins for 22 cases (23.9%) in group 1, and high-grade SIL involvement of the LETZ surgical margins for six cases (18.1%) in group 2. In 13 of the women in group 2, the indication for LETZ was persistent low-grade SIL. DISCUSSION: The percentage of surgical margins involved was similar in the two groups in our study, and comparable to that reported in the literature (16.2 to 26.6%). Our study, like other published studies, thus supports the possibility in certain cases of treating high-grade cervical SIL conservatively with LETZ or minicones. In the 13 women with a diagnosis of persistent low-grade SIL, 11 of whom (84.6%) were infected with a high-risk HPV genotype, LETZ made a diagnosis of occult high-grade SIL. CONCLUSION: LETZ may be an alternative to conization in young women, and it is advisable in cases of persistent low-grade SIL with high-risk HPV infection.

Prognostic factors for the development of vaginal intraepithelial neoplasia.

OBJECTIVE: To identify risk factors for the appearance of vaginal intraepithelial neoplasia (VAIN). MATERIAL AND METHODS: A total of 485 women with abnormal cytologies were followed over three years (2003-2006). They underwent cytolology and colposcopy, and testing for human papillomavirus virus (HPV) infection. If the colposcopy was atypical, a biopsy was performed. RESULTS: A total of 256 women were treated: 161 by cone biopsy, 103 by LLETZ, 12 by repeat conization, and 44 by total hysterectomy. In eight cases VAIN was diagnosed following hysterectomy. The average age at which VAIN appeared was 49.8 years (age range 39-61). Hysterectomy was indicated in two cases of cervical cancer, four cases of persistent high-grade cervical SIL, and two cases of recurrent high-grade cervical SIL. The mean time for the appearance of VAIN following hysterectomy was 3.8 years (range 1-9 years). Of these eight women, seven had HPV infections at high risk for carcinogenesis. CONCLUSIONS: Long-term follow-up cytology is necessary for women treated for high-grade SIL, even after hysterectomy, because of the increased risk of a primary vaginal VAIN lesion, especially in women with high-risk HPV infection.

Rotura uterina asociada a desprendimiento prematuro de placenta normalmente inserta en gestante de 25 semanas / Uterine rupture associated with premature separation of a normally inserted placenta at 25 weeks’ gestation

Se presenta un caso de rotura uterina en paciente secundípara de 25 semanas que ingresó en nuestro centro por rotura prematura de membranas. Se practicó una cesárea de urgencia ante la sospecha de desprendimiento prematuro de placenta normalmente inserta y se objetivó rotura de la cicatriz de la cesárea anterior (AU)

We report a case of uterine rupture in a secundipara at 25 weeks’ gestation who was admitted to our center for premature rupture of membranes. Emergency cesarean section was performed due to suspicion of premature separation of a normally inserted placenta. Rupture of a previous cesarean section scar was observed (AU)

Cancer of the vulva in a 25-year-old woman with VIN III and high-grade cervical SIL--case report.

Human papillomavirus (HPV) infection is associated with an increase in intraepithelial lesions of the genital tract which are often multicentric. Following is a presentation of a case of vulvar cancer in a young woman (25 years of age) with multiple vulvar intraepithelial neoplasia (VIN III) lesions, a high-grade squamous intraepithelial cervical lesion, and a HPV type 16 infection at high risk of oncogenic transformation. This case offers an opportunity to discuss the risk factors that may favor the appearance of these lesions in young women, and their clinical management, diagnosis, and treatment.

Carcinoma de endometrio y ovario sincrónicos / Synchronous primary cancers of the endometrium and ovary

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Synchronous primary cancers of the endometrium and ovary are found in 10% of women with ovarian cancer and 5% of women with endometrial cancer. The classification into synchronous primary cancers or metastasis has different consequences in the prognosis and treatment. But this classification is still difficult. We describe four cases from our service. Endometrioid cancers are the most frequent and have the best prognosis. The median age of the patients is younger than patients with metastasic tumours and the most common sign or symtom is abnormal uterine bleeding. Treatment is still controversial (AU)

Histerectomía. Revisión crítica de las indicaciones actuales / Hysterectomy. A critical review of actual indications

La finalidad de este capítulo es llevar a cabo una revisión pormenorizada de las indicaciones actuales de la histerectomía

The aim of this chapter is to review critically the indications of hysterectomy nowadays

Prevención de la fertilidad femenina en los tratamientos oncológicos. Criopreservación de tejido ovárico / Female fertility prevention in the oncologic treatments. Criopreservation of ovarian tissue

En este capítulo se revisan diversas posibilidades para conservar la fertilidad femenina en pacientes oncológicas: quimioprofilaxis, criopreservación de embriones, oocitos y de tejido ovárico. Se especula sobre opciones futuras

Different options to preserve female fertility in oncologic patients are reviewed in this chapter: Chemoprophylaxis, embryos, oocytes and ovarian tissue criopreservation. It hypothesized over futur options

Prevalence of human papilloma virus infection of the uterine cervix in women with abnormal cervical cytology.

PURPOSE OF INVESTIGATION: To determine the prevalence of human papillomavirus (HPV) using polymerase chain reaction (PCR) in women with abnormal cytology results. METHODS: A prospective study of 215 women with abnormal cytology results referred consecutively to the cervical pathology clinic was carried out. A second cervical cytology using the Bethesda System was performed on all the patients to confirm the initial diagnosis, as well as to test for the presence of HPV by PCR and a colposcopy and punch biopsy in cases presenting with an abnormal pattern on colposcopy. The sensivitiy, specificity, and positive and negative predictive value (PPV and NPV) were calculated using 2 x 2 tables. RESULTS: The women aged 35 years or younger presented a higher percentage of HPV infection (85.6%) than the women over 35 years of age (54%). The highest percentage of women with a positive result for HPV was found in those with a cytological high-grade squamous intraepithelial lesion (HSIL) (85.5%), as compared with 47.4% of the women with a cytological low-grade squamous intraepithelial lesion (LSIL). HPV infection has a high negative predictive value (93.2% of cases) and a high sensitivity (93.5%) for the detection of HSIL by biopsy, although the specificity and positive predictive value were low, 51.5% and 52.1%, respectively. CONCLUSION: Patients with cytological HSIL have a high prevalence of HPV infection.

Cervical cancer and low-risk HPV; a case report.

A case of cervical cancer in a 32-year-old woman with a genotype 6 HPV genital infection that developed from a cervical low-grade SIL after a LLETZ procedure two years before is presented. This case obliges us to reconsider both the benign nature of low-grade lesions and the potentially good prognosis of low-risk HPV infection.

Uterine adenosarcoma diagnosed following hysteroscopic resection of an intrauterine tumour.

Uterine adenosarcoma is a mixed müllerian tumour consisting of a benign epithelial component and a malignant stromal component. It is a rare tumour that represents 8% of uterine sarcomas. We present a case of a 61-year-old woman who underwent a surgical hysteroscopy for postmenopausal metrorrhagia and thickened endometrium detected by ultrasonography. The pathologic diagnosis of the tumour removed by hysteroscopy was uterine adenosarcoma. The description of this case provides an opportunity to review the literature on uterine sarcomas diagnosed by surgical hysteroscopy.

Revisión de las parálisis braquiales neonatales observadas en el Hospital Sant Joan de Déu de Barcelona / Review of brachial plexus palsy in the Sant Joan de Déu Hospital in Barcelona (Spain)

Objetivo: Valoración de los factores de riesgo maternos, neonatales y del parto que pueden condicionar una parálisis braquial del recién nacido. Material y método: Estudio retrospectivo de enero de 1988 a mayo 1999, realizado mediante la revisión de la historia clínica materna y neonatal. Resultados: Durante el período del estudio, se observaron 23 parálisis braquiales de un total de 27.287 partos. Las gestantes que tuvieron un recién nacido con parálisis braquial presentaban con mayor frecuencia obesidad previa y una ganancia excesiva de peso durante la gestación (65,2%). Entre los antecedentes destaca la presencia de diabetes en 4 gestantes. El tipo de parto más asociado a esta lesión fue el instrumentado (73,9%)y se observó una distocia de hombros en 3 de ellos. El peso medio al nacer de los 23 neonatos fue de 4.073,34 g, y en el 56,5% de ellos fue superior a 4.000 g. Hay que destacar que la parálisis braquial se recuperó totalmente en el 60,8% de los casos. Conclusiones: Los factores relacionados con la parálisis braquial son el peso elevado al nacer, el parto instrumentado, la ganancia excesiva de peso, la diabetes y la distocia de hombros

Objective: To evaluate the maternal, neonatal and delivery risk factors that could be associated with brachial plexus palsy in the neonate.Material and method: We performed a retrospective study of maternal and neonatal medical records between January 1988 and May 1999.Results: Among 27 287 deliveries, there were 23 cases of brachial plexus palsy. A total of 65.2% of the patients delivering a newborn with a brachial plexus lesion were overweight before pregnancy and presented excessive weight gain during pregnancy. Four mothers were diabetic. Forceps delivery and vacuum extraction were associated in 73.9% of newborns with brachial palsy and previous shoulder dystocia was observed in three of these. The mean birth weight was 4073.34 g, and 56.5% of newborns weighed more than 4000 g. Notably, 60.8% of the children with brachial palsy made a complete recovery. Conclusions: The factors associated with brachial palsy are weight more than 4000 g, forceps or vacuum delivery, excessive weight gain, diabetes, and shoulder dystocia