Reactive lymphoid hyperplasia of liver mimicking late ovarian cancer recurrence: case report and literature review.

Reactive lymphoid hyperplasia (RLH) is a rare, benign, lymphocytic tumour-like lesion reported in various organs. It has been previously identified in 18 cases in the English-language literature, but only 5 of them were related to oncological disease. No previous cases have been described of RLH occurring in ovarian cancer patients. We describe a case of hepatic RLH which developed in a patient treated for ovarian cancer 11 years previously. Radiological features on computed tomography (CT) scan and PET-CT (positron emission tomography-computed tomography) were strongly suggestive of oncological disease, in contrast to magnetic resonance imaging (MRI); the volume increment of the nodular lesion and the rise in carbohydrate antigen 125 corroborated the hypothesis of malignancy. The patient was subjected to resection of the 7th segment of the liver and the final histological report showed RLH. RLH should be considered in the presence of hepatic lesions in suspected ovarian cancer recurrence. Imaging techniques should be thoroughly investigated to exclude tumor recurrence promptly, in order to avoid unnecessary surgery.

Limits of ¹8F-fluorodeoxyglucose positron emission tomography in recurrence diagnosis of borderline ovarian tumor.

Most borderline ovarian tumors (BOT) occur in young women and exhibit a low malignant behavior. Nevertheless, an accurate long-term follow-up is required because, frequently, recurrence arises after many years from primary treatment, especially in patients affected by BOT with invasive peritoneal implants, which have a worse prognosis. We report the case of a pelvic recurrence of serous BOT firstly suspected by physical examination but misdiagnosed by ¹8F-fluorodeoxyglucose positron emission tomography and computed tomography and identified only by magnetic resonance imaging, 7 years after primary treatment. We also reviewed the literature concerning the role of ¹8F-fluorodeoxyglucose positron emission tomography in the management and follow-up of BOT.

Multiple Bulky Lymph Nodal Metastasis in Microinvasive Cervical Cancer: A Case Report and Literature Review.

Microinvasive squamous cell cervival carcinoma is characterized by an exceptional incidence of lymph nodal metastasis. We report the case of a 45-year-old woman affected by IA1 squamous cell carcinoma, found to have massive pelvic lymph nodal metastasis. After a systematic pelvic and aortic selective lymphadenectomy, at 16 months of follow-up, she is still disease-free. Patients suitable for conservative therapy should be carefully counselled about the established risks and benefits of nondestructive treatment options.

Intraperitoneal paclitaxel as consolidation treatment in ovarian cancer patients: a case control study.

OBJECTIVE: It was the aim of this study to assess the role, feasibility and safety of consolidation intraperitoneal (IP) paclitaxel in patients affected by advanced ovarian cancer. METHODS: Patients affected by advanced ovarian cancer with complete pathological response after standard treatment were enrolled in this study. The consolidation chemotherapy schedule consisted of 12-16 cycles of IP paclitaxel, 60 mg/mq weekly (group A). Chemotherapy was delivered with a direct puncture under ultrasonographic guidance at each cycle. Survival data of this group of patients were compared with those from a control group with analogous characteristics submitted to observation only (group B). RESULTS: Seventy patients were included in the study, 28 in group A and 42 in group B. Treatment-related toxicity was mild. In 3/28 patients (11%), technical difficulties in accessing the peritoneum were observed. Median time to recurrence was 25 months (range 4-64) in group A and 17.5 months (range 2-60) in group B. Estimated 3-year disease-free survival was 56 and 33% (p < 0.05) in group A and B, respectively; no significant difference in 3-year overall survival was observed (87 vs. 83%; p value not significant). CONCLUSION: Weekly IP consolidation chemotherapy with paclitaxel 60 mg/mq is well tolerated and, in this experience, a prolongation of progression-free survival was observed.

Vaginectomy: a minimally invasive treatment for cervical cancer vaginal recurrence.

OBJECTIVE: Radiotherapy and/or pelvic exenteration represent the treatment of vaginal recurrence, but the prognosis remains unsatisfactory and with long-term complications. We investigated the possible role of vaginectomy for isolated vaginal relapse (IVR) in cervical cancer (CC). METHODS: Patients with vaginal CC recurrence were evaluated for surgical treatment consisting in vaginectomy. Data were prospectively collected and analyzed to identify independent prognostic factors. RESULTS: Twenty-nine patients with IVR from CC were enrolled. Early and late complications were observed in 7 (24%) and 6 (21%) patients, respectively. After a median follow-up of 57.5 months (range, 8-100 months), 16 patients (55%) were disease-free. The 5-year overall survival and progression-free survival rates were 70.5% and 59.4%, respectively. CONCLUSIONS: In carefully selected patients, vaginectomy may be considered a therapeutic option for IVR. Older patients with long disease-free interval and small recurrences benefit the most from this bladder-sparing surgical technique.

Malignancy in endometrial polyps: a 12-year experience.

OBJECTIVE: Endometrial polyps (EPs) are common pathological lesions in all women. The objective of this study was to evaluate the risk of malignancy of EPs and to investigate whether clinical parameters may predict the histopathologic features of these lesions. STUDY DESIGN: A retrospective study was conducted from January 1995 to December 2006 and all consecutive 1242 cases with clinical EPs were included. The charts of all these women were reviewed and clinical data were related to histopathologic results. RESULTS: Histologically, polyps were distinguished as benign, premalignant, and malignant. Overall, 95.2% benign polyps, 1.3% premalignant, and 3.5% malignant lesions were detected. When clinical variables were considered, patient age, menopause, presence of abnormal uterine bleeding, and hypertension were statistically significant characteristics related to premalignant and malignant features. CONCLUSION: Older menopausal bleeding patients with hypertension are at high risk for premalignant and malignant polyps. Therefore, besides abnormal bleeding symptoms, this kind of patient needs to have the polyps removed.

Inguinofemoral lymphadenectomy: randomized trial comparing inguinal skin access above or below the inguinal ligament.

BACKGROUND: Groin wound breakdown, lymphoceles, cellulitis, and chronic leg edema are the most frequent complications of inguinal lymphadenectomy, resulting in severe patient discomfort and significant lengthening of postoperative stay. Despite all innovations, complication rates are still high and inevitable. Our experience suggests that cutaneous flap preparation, identification of the Camper fascia, and preservation of the most lateral lymphatics decrease associated morbidity. The aim of this study is to analyze whether different cutaneous skin flap preparations and their different devascularization (above or below the inguinal ligament), resecting all the lymphofatty tissue, reduce groin wound complications, and whether the same therapeutic approach and number of lymph nodes removed are comparable. METHODS: This prospective randomized clinical trial of 62 consecutive patients affected by vulvar carcinoma requiring inguinal lymphadenectomy compared skin inguinal incision carried out 3-4 cm above the inguinal ligament (group A) or below it (group B). RESULTS: Inguinal dehiscence was present in 17 of 53 (32.1%) patients in group B and in 9 of 54 (16.7%) in group A (P=0.10). Lymphocele was observed in 10 of 53 lymphadenectomies (18.9%) in group B and in 3 of 54 dissections (5.6%) in group A (P=0.07). Upper incision allows more precise identification of the Camper fascia, is less painful, and gives better cosmetic results. Moreover, there may be advantage, albeit not statistically significant, regarding flap length, wound dehiscence rate, and speed of wound healing. There was no difference in chronic leg edema, number of nodes removed, or hospital stay.

Neoadjuvant chemotherapy followed by radical surgery in patients affected by vaginal carcinoma.

BACKGROUND: Radiotherapy represents the standard treatment for patients affected by FIGO stage II vaginal cancer. Several authors have suggested that neoadjuvant chemotherapy followed by radical surgery might be a valid treatment option in patients affected by cervical cancer. The objective of this study was to analyse the feasibility and results obtained by neoadjuvant chemotherapy followed by surgery in patients affected by invasive vaginal cancer with paravaginal tissue involvement not reaching the pelvic side wall. METHODS: Eleven patients affected by FIGO stage II vaginal cancer were treated with paclitaxel 175 mg/m(2) and cisplatin 75 mg/m(2) every 21 days for three courses followed by radical surgery. RESULTS: All patients were subjected to the 3 planned chemotherapy courses. Three (27%) patients achieved a complete clinical response and seven (64 %) patients achieved a partial clinical response. All patients were subjected to radical hysterectomy and vaginectomy. At a median follow up of 75 months two (18%) patients suffered a disease recurrence and one of these died of disease. CONCLUSIONS: Neoadjuvant chemotherapy followed by radical surgery is a feasible therapeutic strategy with good short- and long-term results. In women affected by vaginal cancer, a larger series reporting the result of this therapeutic strategy or the results obtained by surgery alone will aid physicians to choose the best therapeutic strategy for each individual patient.

Urethral coitus in a patient with a microperforate hymen.

Microperforate hymen is a rare condition consisting of a tiny hymeneal orifice with normal female genitals. A woman had microperforate hymen in which diagnosis and treatment was performed after decades of urethral coitus.

Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele.

STUDY OBJECTIVE: To reveal the efficacy and feasibility of concomitant anterior colporrhaphy and tension-free vaginal tape-obturator to treat stress urinary incontinence (SUI) and concomitant cystocele. DESIGN: Controlled trial without randomization (Canadian Task Force classification II-1). SETTING: University hospitals in Rome, Italy. PATIENTS: Fifty consecutive patients with SUI associated with symptomatic cystocele were enrolled into the study. Exclusion criteria were: uterine prolapse greater than or equal to 1, rectocele greater than or equal to 1, overactive bladder, overactive bladder symptoms, intrinsic urethral sphincter deficiency, urinary retention, previous anti-incontinence and/or prolapse surgery, neurologic bladder, psychiatric disease, body mass index greater than 30, and elevated intraabdominal pressure. The preoperative evaluation consisted of: complete history, physical examination, 3-day voiding diary, and urodynamic testing. The International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) was used to subjectively quantify the patient perception of SUI symptom severity. INTERVENTIONS: All patients underwent an ultralateral anterior colporrhaphy plus tension-free vaginal tape-obturator. MEASUREMENTS AND MAIN RESULTS: In all, 43 (91%) and 46 (92%) patients were objectively cured for cystocele and SUI, respectively. The median operating time, blood loss, and hospitalization were 43 minutes (range 35-56), 64 mL (range 40-148), and 1 day (range 1-2), respectively. Overall early postoperative complication rate was 16%, although all were minor. Only 1 patient, at 12-month follow-up, developed tape erosion that required surgical removal. The ICIQ-UI SF questionnaire scores were 13.4 +/- 6.8 and 3.5 +/- 3.2 (p <.01) between preoperative and 12-month follow-up, respectively. CONCLUSION: Concomitant tension-free vaginal tape-obturator plus ultralateral anterior colporrhaphy are feasible and safe procedures for the treatment of SUI and with associated cystocele with a high success rate and low intraoperative and postoperative complications rate.

Late breast cancer recurrence to the uterine cervix with a review of the literature.

The cervix is a possible site of metastasis from any primary malignancy, but no specific indication on follow-up examination is present. We present an asymptomatic patient with isolated breast cancer cervical recurrence diagnosed by colposcopy after 11 years from primary disease. After a PubMed search and a review of current guidelines, no indication to follow-up examination regarding the cervix is present. The adoption of colposcopy in cancer survivors might be an aid to gynecologists in diagnosing cancer recurrence. Cancer survivors might benefit from a more thorough gynecologic examination as compared with the simple Papanicolaou test.

Cancer testis antigen expression in primary and recurrent vulvar cancer: association with prognostic factors.

Cancer testis tumour associated antigens (C/T-TAAs) were investigated in several gynaecologic and non-gynaecologic neoplasms as possible prognostic markers and targets for immunotherapy. The objective of the present study was to evaluate C/T-TAA expression patterns and prognostic significance in patients affected by vulvar cancer. Melanoma antigen E (MAGE)-A1, MAGE-A4 and NY-ESO-1 expression was determined by immunohistochemistry in paraffin-embedded tissue specimens from 45 primary and 14 recurrent vulvar carcinomas treated with surgery. MAGE-A1, MAGE-A4 and NY-ESO-1 were expressed in 25 (42%), 38 (64%) and 40 (68%) of the 59 samples, respectively. MAGE-A4 was significantly more frequently expressed in tumours with lymph node metastases (p<0.002) and in recurrent tumours (p<0.02). NY-ESO-1 was more highly expressed by moderately or poorly differentiated tumours (p<0.01). This study demonstrates that vulvar cancer frequently expresses C/T-TAAs. Antigen expression correlates with the presence of lymph node metastases and poor tumour differentiation.

Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy: a prospective, randomized, multicenter study.

STUDY OBJECTIVE: The aim of this study was to compare operative and early postoperative outcomes of laparoscopic-assisted vaginal hysterectomy (LAVH) and minilaparotomy in a randomized clinical trial including patients undergoing total hysterectomy for benign gynecologic disease and having 1 or more of the generally considered contraindications to vaginal route. DESIGN: Prospective, randomized, multicenter trial (Canadian Task Force classification I). SETTING: Departments of Gynecology from 3 major university hospitals in Rome. PATIENTS: Eighty-one patients who were candidates for abdominal hysterectomy. INTERVENTIONS: Laparoscopic-assisted vaginal hysterectomy and minilaparotomy hysterectomy. MEASUREMENTS AND MAIN RESULTS: Forty patients were randomized to LAVH and 41 to minilaparotomy. Characteristics of patients and indications for surgery in the 2 arms were comparable. In the minilaparotomy group, complications were as follows: 1 case (2.4%) of delayed laparotomy with 2 units of red blood cell transfusion, 2 cases (4.8%) of wound infection, and 3 cases (7.3%) of fever of unknown origin. No minor or major complications were observed in the LAVH group. Postoperative visual analog scale pain scores at days 1 and 2 were significantly lower in the LAVH group (p <.05). The complication rate between the 2 groups was significantly lower for LAVH (p = .026). CONCLUSION: Because LAVH was associated with significantly lower early postoperative pain scores and complication rates, in general LAVH should be preferred to minilaparotomy hysterectomy when the vaginal approach cannot be used.

An update in neoadjuvant chemotherapy in cervical cancer.

More than two decades have passed since neoadjuvant chemotherapy has been introduced in the clinical practice. After several pilot studies, randomized trials and meta-analysis have confirmed the validity of this therapeutic strategy and in particular of neoadjuvant chemotherapy followed by radical surgery. Several open questions still remain unanswered and in particular no standard drug regiment is unanimously accepted. In this paper we describe how this treatment has evolved since its original introduction in the early eighties and describe possible drug regimens with their supporting evidence that can be adopted by physicians worldwide.

Continent ileocolonic urinary diversion (Rome pouch) for gynecologic malignancies: technique and feasibility.

OBJECTIVE: To describe the technique, feasibility and early complications of "Rome pouch" urinary diversion. METHODS: Thirty-five consecutive patients affected by advanced or recurrent gynecological cancers who required anterior or total pelvectomy entered the study. Rome pouch technique starts with the transection of terminal ileum about 12 cm from the ileocecal valve; the large colon is transected 15-20 cm distal to the hepatic flexure. The intestinal wall tension and internal pressure are reduced using 5-8 transverse teniamyotomies of the cecum. The efferent segment of the pouch is created either with the appendix or with the distal ileum. Operative data, intra- and early postoperative complications were recorded. RESULTS: Between February 2000 and March 2006, an ileocolonic urinary diversion (Rome pouch) was carried out in 35 patients affected by advanced or recurrent gynecologic malignancies. The average operative time to complete the anterior and total exenteration including reconstruction procedure was 285 (range, 230-350) and 320 (range 280-415) min, respectively. The average time in performing the Rome pouch technique was 60 min (range, 45-90). Overall postoperative complication rate (major and minor complications) was 82% (29 patients). Febrile morbidity occurred in 26 patients (74%). Wound complications and pelvic collection were found in 7 (20%) and 6 (17%) patients, respectively. CONCLUSION: Our experience demonstrated that Rome pouch technique represents a valid alternative in gynecology oncology for continent urinary diversion. This technique showed low rate of medical and early urologic complications. The simplicity of performing the procedure and the reduced operating time are the best goals reached by Rome pouch technique. Future comparative trials will better define the role that the Rome pouch will have in these patients.

Neoadjuvant chemotherapy followed by radical surgery in patients affected by FIGO stage IVA cervical cancer.

BACKGROUND: Concomitant chemoradiotherapy represents the standard treatment for patients affected by locally advanced cervical cancer. Survival rates in patients affected by FIGO stage IVA disease remain poor. Some authors have suggested that neoadjuvant chemotherapy followed by radical surgery might be a valid alternative to standard treatment. The objective of this study was to analyze the feasibility and results obtained by neoadjuvant chemotherapy in patients affected by stage IVA disease. METHODS: Eighteen patients affected by FIGO stage IVA cervical cancer were treated with 175 mg/m(2) paclitaxel and 75 mg/m(2) cisplatin every 21 days for three courses followed by radical surgery when feasible. RESULTS: All patients were subjected to the three planned chemotherapy courses. Two patients achieved a complete clinical response, and 10 patients achieved a partial clinical response. Ten patients were subjected to anterior pelvic exenteration, whereas the remaining eight patients were treated with chemotherapy, radiotherapy, and concomitant chemoradiotherapy. The estimated 3-year and 5-year overall survival rates were 47.4% and 31.6%, respectively. Patients eligible for surgery benefited from significantly longer survival rates. CONCLUSIONS: Neoadjuvant chemotherapy followed by radical surgery is feasible in approximately half of patients affected by FIGO stage IVA cervical cancer. Overall survival rates appear similar to those reported with concomitant chemoradiotherapy. Patients who are amenable to radical surgery after chemotherapy may benefit from long-term survival rates.

CO2 laser therapy of the Bartholin's gland cyst: surgical data and functional short- and long-term results.

The Bartholin's gland cyst is a condition that occurs in approximately 2% of women, most of whom are of reproductive age. Although benign, it is associated with significant patient discomfort. Definitive treatment involves the surgical removal of the entire cyst. The objective of this study was to describe an alternative conservative surgical technique with CO(2) laser adopted in our institution and to evaluate the feasibility, complication rate, and results obtained with this technique in an office setting. Our study showed that CO(2) laser treatment of the Bartholin's gland cyst can be carried out safely in an outpatient setting, with minimum patient discomfort and high long-term cure rates.

Secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer.

BACKGROUND: Secondary surgical cytoreduction (SCR) represents a promising therapeutic strategy for patients affected by ovarian cancer disease recurrence. The aim of this prospective observational trial was to analyze the role of SCR in patients with platinum-sensitive ovarian cancer. METHODS: Patients with platinum-sensitive ovarian cancer underwent SCR by a single surgical team. Clinical and oncologic data were prospectively recorded. A total of 47 patients underwent SCR from 1999 to 2003. RESULTS: The mean operating time was 210 minutes, and mean blood loss was 500 mL. The most frequent surgical procedures carried out were splenectomy, lymphadenectomy, bowel resection, and extensive peritonectomy. Optimal cytoreduction was achieved in 41 patients. Thirty-seven patients had no visible tumor at the end of SCR. Overall median survival was 49 months. Patients who achieved optimal residual disease had a median survival of 61 months, whereas patients who had residual disease >1 cm had a median survival of 19 months. CONCLUSIONS: Positive CA-125 (cancer antigen 125) was identified as a negative prognostic factor at multivariate analysis. After careful selection, optimal cytoreduction can be achieved in most patients who are subjected to SCR with acceptable morbidity. Residual tumor and CA-125 represent the most important prognostic factors.

Resectoscopic versus bipolar electrode excision of endometrial polyps: a randomized study.

OBJECTIVE: To evaluate operative resectoscopy versus hysteroscopic bipolar electrode excision for the treatment of endometrial polyps. DESIGN: Prospective, randomized study. SETTING: Tertiary-care university hospital. PATIENT(S): One hundred consecutive patients with endometrial polyps. INTERVENTION(S): Patients underwent diagnostic hysteroscopy, and after assignment on a random basis, they underwent polyp excision either by operative resectoscopy or by a bipolar electrode passed through the operating sheath of a small-caliber hysteroscope. MAIN OUTCOME MEASURE(S) AND RESULT(S): Operating times, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. The two procedures did not differ in total surgery times. In subgroup analysis, the resectoscope was faster for large polyps (>2 cm) and for polyps with a fundal implant. The bipolar electric probe was faster for small polyps (<2 cm) and for polyps with a nonfundal implant. CONCLUSION(S): Operative resectoscopy appears to be the technique of choice for endometrial polyps >2 cm or with a fundal implant. Bipolar electrode excision appears to be preferable for smaller, nonfundal polyps.

Minilaparotomy versus laparoscopy in the treatment of benign adnexal cysts: a randomized clinical study.

OBJECTIVE: To determine advantages and disadvantages of minilaparotomy and laparoscopy in managing patients affected by benign adnexal masses. STUDY DESIGN: Prospective, randomized, clinical trial on 127 patients affected by adnexal cysts. Patients were submitted to adnexal surgery through a laparoscopic or minilaparotomy approach on a random basis. RESULTS: Hundred and twenty-seven patients were enrolled in the study and randomly assigned to laparoscopy (63 patients) or minilaparotomy (64 patients). Characteristics of the patients and of the cysts were homogeneous between the two groups. No significant differences between the two groups were recorded in terms of operative time, intraoperative complications, ileus, length of stay and recovery time. The intraoperative rupture rate of the cyst was significantly higher in the laparoscopy group only in a subgroup of patients affected by cysts greater than 7 cm in diameter (p=0.01). Three patients randomized to laparoscopy required conversion to laparotomy. Concerning postoperative outcomes, postoperative pain and minor complications were significantly less in patients undergoing laparoscopy (p=0.001 and 0.04). CONCLUSIONS: Operative laparoscopy appears to be the preferable approach for the management of adnexal cysts. Minilaparotomy can be considered a mini-invasive approach as well, with acceptable operative and postoperative outcomes, and is a suitable alternative in case of contraindications to laparoscopy.