The application of magnetic resonance imaging in preoperative evaluation of patients with endometrial carcinoma.

PURPOSE: The aim of this paper was to assess the usefulness of the preoperative application of magnetic resonance (MRI) imaging in patients with confirmed endometrial carcinoma. METHODS: This prospective study included 50 patients with endometrial cancer. MRI was used for preoperative disease staging and in planning the operative treatment. The parameters monitored by MRI were compared with the findings of curettage pathological examination. Estimated were the depth of myometrial invasion, the involvement of the cervix by the tumor, the presence of adnexal metastases and regional lymph nodes. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of the MRI in relation to the aforementioned clinicopathological parameters were assessed. RESULTS: The presence of myometrial invasion was estimated with 100% specificity, 86% sensitivity, 100% PPV and 40% NPV. The estimation of the depth of myometrial invasion (>or<50%) was defined with 89% sensitivity, 54% specificity, 83% PPV and 60% NPV. MRI provided valuable data about cervical invasion (100% PPV for the presence of cervical invasion and 55% PPV for the depth of cervical invasion), thereby helping to decide on the kind of surgical intervention, the choice of approach (open or laparoscopic surgery) and the choice of the surgeon. CONCLUSION: MRI is useful and reliable in preoperative evaluation. The information obtained by MRI provides space and time for planning the treatment modality.

Recurrence of cervical intraepithelial neoplasias with negative cone margins: risk factors.

PURPOSE: The percent of young patients treated for cervical intraepithelial neoplasias (CIN) has been increasing, thus it is very important to define patients in high risk for relapse. The aim of this study was to establish any possible association of persistent human papillomavirus (HPV) infection, age, smoking, parity, use of oral contraceptives, and Chlamydia infection, with relapse of CIN. METHODS: Between March 2006 and March 2009 a prospective clinical study was performed at the Clinic of Obstetrics and Gynecology in Nis, with the study group comprising the first 35 patients with disease relapse after conization and the control group consisting of 30 patients with more than one year after treatment without relapse. HPV typization was done at the Laboratory for Molecular Biology and Cytogenetics of the Clinical Centre Nis using polymerase chain reaction (PCR). RESULTS: A statistically significant higher percentage of recurrences with lower pathologic stage (CIN I) was found in younger women (below 29 years) (p<0.01). Women in the control group were more commonly non smokers (56.66 vs. 40%) but without statistical significance (p>0.05). The distribution of smoked cigarettes in the study and control subjects showed no statistically significant difference (p>0.05). Patients with recurrences were more commonly HPV-positive compared to controls (68.57 vs. 6.66%; p <0.05). In the study group, HPV-positive smokers recurred with more advanced grades (CIN III and microinvasive carcinoma/MIC; p<0.01). In non smokers, the severity of recurrence was not statistically correlated with HPV positivity. CONCLUSION: Persistent HPV infection, smoking associated with HPV infection and more advanced age were demonstrated to be of statistical significance for CIN recurrence. Parity, use of oral contraceptives, Chlamydia infection, and smoking as independent etiologic factors were not significantly associated with CIN relapse.

Primary carcinoma of the vagina.

In this paper we reviewed the risk factors for primary carcinoma of the vagina (PCV), diagnostic and therapeutic modalities, and principles leading to rational decision-making in the individualized management of vaginal carcinoma patients. The review was based on the recent literature and our own years- long experience with the disease. PCV is a rare gynecologic malignancy accounting for about 2% of all neoplasms of the female genitals. Most of the affected women are over 60 years of age, peaking between 70 and 80 years. Only 10-15% of patients are below 50 years. Histopathologically, most common are squamous cell carcinoma (80-90%) and adenocarcinoma (4-10%). The leading risk factor for vaginal intraepithelial neoplasia (VAIN) and subsequent squamous cell vaginal carcinoma is long-lasting infection with human papillomavirus (HPV) type 16. Prognosis of the disease depends on several factors, the most important of which are age, histologic type, and tumor stage. Survival depends on the disease stage. Five -year survival rates are about 95% for stage 0, 75% for stage I, 60% for stage II, 35% for stage III, 20% for stage IVa, and 0% for IVb stage. Due to its being a rare entity, there are still controversies as to the most optimal treatment. Individualized treatment approaches have been increasingly used. In most centres, standard treatment for this cancer is radiotherapy. Some reports have shown that surgery might also be an option, while in some centres radiation is supplemented by cisplatin-based chemotherapy. The supposed advantage of radiotherapy is the preservation of the anatomy and function of the vagina. We believe that there are certain psychologic benefits with the preservation of the vagina, regardless of its function. However, preservation of the vaginal function after treatment of invasive vaginal cancer is a rare phenomenon, both in the literature and from our own experience.

Modern treatment of invasive carcinoma of the uterine cervix.

Treatment of invasive cervical carcinoma is determined by the clinical disease stage. Microinvasive carcinoma of the uterine cervix, due to its limited metastatic potential, is usually curable with non-radical treatment. There are no standard approaches to the treatment of stage Ib-IIa carcinoma of the uterine cervix. Both radical surgery and radical radiotherapy are utilized with similar efficacy but with different associated morbidity and complications. Stage Ib1 was commonly treated with radical hysterectomy plus pelvic lymphadenectomy. Laparoscopically-assisted radical vaginal hysterectomy demonstrated similar efficacy and recurrence rates for this disease stage. In cases where fertility is to be preserved, radical vaginal trachelectomy is a valid option for small cervical cancers. Among the papers dealing with bulky cervical disease (stages Ib-IIa) a great deal of disagreement is evident. Some oncologic centres prefer primary surgery with postoperative radiotherapy, with or without chemotherapy, while others prefer primary chemoradiotherapy. Moreover, as a possible alternative, neoadjuvant chemotherapy followed by radical surgery is recommended for stage Ib2 disease. Simultaneous chemoradiation is being introduced as a new standard for advanced cancer, since it has been clearly demonstrated that it can prolong disease-free and overall survival. The treatment of recurrent carcinoma depends on the type of previous treatment, site and extent of recurrent disease, and on the disease-free period and general health of the patient. In conclusion, the decision on the treatment approach for invasive carcinoma of the uterine cervix should be individualized, based on numerous factors, such as disease stage, general health of the patient, cancer-related factors, in order to choose the best approach with minimal complications.

Risk factors and adjuvant chemotherapy in the treatment of endometrial cancer.

Endometrial carcinoma is the most common and potentially curable gynecologic malignant neoplasm. The staging of endometrial cancer, according to the International Federation of Gynecology and Obstetrics (FIGO), is surgical. Recent studies suggest a therapeutic benefit associated with extensive retroperitoneal lymph node evaluation to determine the disease extent and thereby more effectively direct potentially life-saving adjuvant therapy. Due to the increasing number of endometrial cancer patients who undergo surgical staging, some independent prognostic factors have been identified in early stages (stage I-II), including lymph-vascular space involvement, histologic grade 3, aggressive histologic subtypes (uterine papillary serous carcinoma, clear cell carcinoma), depth of myometrial invasion, cervical invasion and the age of patients. Adjuvant radiation therapy, known to offer survival benefit in advanced-stage disease, may also offer survival benefit in intermediate-risk surgical stage I, but this is followed by a significant risk of serious complications. Based on randomized clinical trials, this review identified that only a limited body of evidence is available which can help clinicians make decisions about adjuvant chemotherapy of patients with high-risk stage I and II, as well as stage IIIA endometrial cancer. Further investigations are required to define the subgroup of patients who benefit from postoperative adjuvant chemotherapy. In addition, the optimal regimen remains to be defined as all of them (doxorubicin/cisplatin--AP, cyclophosphamide/ doxorubicin/cisplatin--CAP, paclitaxel/carboplatin--TC, paclitaxel/doxorubicin/cisplatin--TAP) cause significant toxicity. Thereby, combination of carboplatin plus paclitaxel represents an efficacious, low-toxicity regimen for managing intermediate-risk surgical stage I, as well as advanced or recurrent endometrial cancer.

[Facial nerve injuries caused by firearms]. / Povrede facijalnog nerve izazvane vatrenim oruzjem.

In the period from 1990 to 1994, 52 facial nerve injuries caused by fragments firearm projectiles were managed. Their features (localization, severity and extensiveness) were correlated with 37 nerve injuries in blunt head injuries with fracture of temporal bone. In blunt head injuries, 81.1% patients were with the nerve lesion in the area of geniculate ganglion (labyrinthine and tympanic segment). Compression of nerve with bone fragments of fallopian tube was found in 56.8% cases, the cleft of neural sheath and intraneural hematoma were rarer, while the nerve tear was not found in any injured. The distal part of mastoid and beginning part of parotid nerve segment were injured in over 70% cases of gunshot injuries, and in 38.5% cases the injury was multiple. Direct suture was performed in 8 nerve injuries, neuroplasty in 6, and the other injuries were managed by skeletization of fallopian tube, nerve decompression or some other microsurgical procedure. Micro-surgery was performed 7-14 days after the injury.