Corrigendum: Laparoscopic myomectomy - The importance of surgical techniques.

[This corrects the article DOI: 10.3389/fmed.2023.1158264.].

Fetal sacrococcygeal immature teratoma - report of two cases and review of the literature.

Sacrococcygeal teratomas (SCTs) are rare congenital tumors. With the improvement of diagnostic imaging methods and follow-up protocols in pregnancies, in utero detection of these tumors has increased. Despite these progresses, SCTs may present difficulties in establishing in utero diagnosis and subsequent management. We present two cases of SCT in 18 weeks, respectively 22 weeks pregnancy, diagnosed using ultrasound imaging and pathologically confirmed. Also, the article aims to recapitulate clinicopathological aspects and prognosis of these lesions, following the review of the literature.

The Risk of Obstetrical Hemorrhage in Placenta Praevia Associated with Coronavirus Infection Antepartum or Intrapartum.

Background and Objectives: The aim was to evaluate the severity of obstetrical bleeding in the third trimester associated with COVID infection in placenta previa and accreta. Materials and Methods: A retrospective study was conducted to compare the risk of obstetrical bleeding in the case of placenta previa with or without associated SARS-CoV-2 infection. Patients presenting with placenta previa before labor were classified into three groups: group A (control) as no infection throughout their pregnancy, group B as confirmed infection during the 1st trimester, and group C as confirmed infection at the time of delivery. Infected patients were stratified according to the severity of signs and symptoms. The severity of obstetrical hemorrhage at birth was assessed quantitatively and qualitatively. All placentas were analyzed histologically to identify similarities. Results: Prematurity and pregnancy-induced hypertension appear significantly related to SARS-CoV-2 infection during the 3rd trimester. Placenta accreta risk increases significantly with infection during the 1st trimester. No statistically significant differences in the severity of hemorrhage associated with childbirth in cases with placenta previa between groups A and C but increased obstetrical bleeding mainly due to emergency hemostatic hysterectomy in group B driven by placenta accrete were detected. Obstetrical hemorrhage at birth in the case of coexistence of the infection was found not to correlate with the severity of the viral disease. Meanwhile, the number of days of hospitalization after birth is related to the specific treatment of COVID infection and not related to complications related to birth. Conclusions: The study finds an increased incidence of placenta accreta associated with placenta previa in cases where the viral infection occurred in the first trimester of pregnancy, associated with an increased incidence of hemostasis hysterectomies in these patients. Placental histological changes related to viral infection are multiple and more important in patients who had COVID infection in the first trimester.

Operator experience impact on the evaluation of still images of a first trimester cardiac assessment protocol.

OBJECTIVE: Congenital heart disease (CHD) is the most common birth defect and represents the leading cause for mortality and morbidity in infants and young adults. Early fetal echocardiography is usually considered a highly specialized scan. The goal of this study is to evaluate the impact of operator's experience in assessing still images of the 4-chamber view and 3-vessels view and to evaluate the feasibility and the performance of a first trimester screening protocol for CHD. METHODS: An online questionnaire consisting of still images of the 4-camber view and 3-vessel view from 50 normal and abnormal cases was reviewed by an expert group made of seven obstetricians specialized in fetal medicine and a nonexpert group made of 13 obstetricians that are certified in ultrasound. After individually visualizing each image set made of the 4-chamber view and 3-vessel view, they had to conclude if the case was normal or abnormal and what images were abnormal. RESULTS: A total of 50 image sets of both normal and abnormal fetal hearts were examined by the 20 reviewers, resulting in 1000 evaluations. The expert group achieved a detection rate of 97.1% with a false positive rate of 5.7%. The nonexpert group achieved also a good detection rate of 91.3% but with a much higher false positive rate of 33.9%. The most frequently missed CHD involved the great arteries and had a normal 4-chamber view. In the majority of false positive cases the 3-vessel view was incorrectly interpreted as abnormal. CONCLUSIONS: A screening protocol for CHD, based on the 4-chamber view and 3-vessel view alone can offer a good detection rate for CHD with a small false positive rate, but only if it is implemented by highly specialized sonographers.

Ultrasound Patterns in the First Trimester Diagnosis of Congenital Heart Disease.

Congenital heart disease (CHD) is the most common birth defect, with a reported prevalence of 5-12 per 1000 live births. Very recently, the American Institute of Ultrasound in Medicine published a guideline recommending the use of the four-chamber and the three-vessel and trachea views to screen for CHD in the first trimester of pregnancy. Our aim is to present abnormal image patterns that are seen in the four-chamber, three-vessel, and trachea views of the fetal heart in the first trimester and to describe their association with specific CHD types. We used a total of 29 cases of CHD from the archives of Filantropia Hospital and the Maternal and Child Health Institute (INSMC) fetal medicine units. We selected cases with a clear and well-documented diagnosis of the CHD type. We identified a series of repeating color doppler flow patterns seen in the four-chamber, three-vessel, and trachea views of the studied cases. Our observations could be developed into a diagnosis algorithm to orientate the examiner to the most likely type of CHD in individual cases.

Inherited thrombophilia is significantly associated with severe preeclampsia.

Methods to prevent the development of pathologies due to placental dysfunctions, such as gestational hypertension and preeclampsia, are the main approaches for obtaining the best maternal and fetal antepartum and postpartum prognosis. During 5 years of study (January, 2015 to December, 2019), the cases of pregnancy and puerperium complicated with pathology due to placental dysfunction were analyzed. The main objective was to determine the magnitude of the impact of thrombophilia on the development of an entity of gestational hypertension disorder. We compared the impact of thrombophilia and its associated complications in patients with gestational hypertension with moderate and severe preeclampsia. Thus, we found obesity, thrombophilia, and underlying cardiac pathology to be significant risk factors for severe preeclampsia. Regarding the comparative analysis of the risk factors and complications associated with patients with mild preeclampsia compared with those with severe preeclampsia, the presence in severe preeclampsia of thrombophilia, endocrine, liver, and cardiac pathology was higher and, a higher rate of complications was observed; complications included fetal death, intrauterine growth restriction (IUGR), prematurity, fetal arrhythmia with acute fetal distress, HELLP syndrome, and placental abruption. Thrombophilia has a significant effect on the development of severe preeclampsia, and oligohydramnios as specific complication of mild preeclampsia. Factors indicating an increased risk of progression from mild preeclampsia to severe preeclampsia are in addition to inherited thrombophilia the underlying pathologies, namely cardiac, hepatic, and endocrine factors.

Breast cancer mortality gaps in Romanian women compared to the EU after 10 years of accession: Is breast cancer screening a priority for action in Romania? (Review of the Statistics).

Breast cancer remains the most common cause of morbidity and mortality by cancer in females worldwide, even though it is largely preventable through population screening. Despite notable progress in the last years in the EU, breast cancer screening programs still maintain wide variations among countries and socio-economic groups. This statistical review aimed to investigate the breast cancer-related health gaps in Romanian women compared to the average EU female population after 10 years of accession (2007-2016). We evaluated breast cancer-related deaths, age-standardized mortality rates and contribution of breast cancer to life expectancy. Trends and percentage changes were compared between Romania and EU-27 for breast cancer, all cancer and all causes of mortality. We found a higher increase of breast cancer deaths in Romania, an increasing trend of mortality (opposite to EU) and a contribution to life expectancy at birth that increased gradually from 0.45 to 0 48 years. All these health gaps compared to EU are aggravated by the fact that no population screening for breast cancer is organized in the country. The opportunities for organizing such a program are consistent, but they should be increased in the future, in order to control the health gap between Romania and EU.

Cervical Cancer Mortality in Romania: Trends, Regional and Rural-Urban Inequalities, and Policy Implications.

Background and Objectives: Despite being largely preventable, cervical cancer mortality still remains an important public health problem globally, in Europe, and in Romania. The European Union member states are urged to implement systematic, population-based screenings for cervical cancer, but the programs developed by the countries remain very heterogeneous. This study aimed to investigate the differences in cervix cancer mortality between Romania and EU and within Romania over the last two decades and to reveal the major sources of inequalities and the policy implications. Materials and Methods: We analyzed the number of deaths and the mortality rates by cervical cancer, standardized using the direct method, over two decades (2001-2016 for the EU, and 2001-2019 for the national and sub-national analyses). Trends, mortality reduction over the years, and mortality differences at the beginning and end of the time interval have been calculated for the EU and Romania, at national and sub-national levels (rural-urban and regions). Results: Our results revealed differences in cervical cancer mortality between Romania and EU and within Romania (among regions and rural-urban areas). These differences used to be very high in the past and are still persisting. Conclusions: The country should revisit its national cervical cancer screening program, which has been implemented for many years, but with a very limited participation rate. Due to the similar problems existing in Central-Eastern Europe, targeted support from the EU for the members from this geographical area could contribute to the minimization of differences in cervical cancer mortality among the EU members.

Umbilical cord lactate compared with pH as predictors of intrapartum asphyxia.

Despite advances in fetal monitoring during labor, one of the most critical causes of neonatal death and neurologic injuries remains intrapartum asphyxia. Umbilical cord gases can be used to detect acidosis and fetal distress. We conducted a retrospective, multicenter study to evaluate umbilical cord blood pH and lactate as a mean of evaluating the degree of intrapartum hypoxia and also to establish which of the two is more reliable in predicting morbidity in term neonates. The present study utilized a total of 124 cases that met the criteria for intrapartum asphyxia and 150 normal term newborns that were randomly selected as case control. Both umbilical cord lactate and pH proved to be accurate predictors of neonatal morbidity caused by intrapartum hypoxia. Lactate proved to be superior to pH in predicting adverse neonatal outcome. The greatest sensibility and specificity in predicting intrapartum asphyxia were achieved in our study by using a cutoff value of 3.75 mmol/l for lactate and 7.24 for pH.

Implications of human T-lymphotropic virus in pregnancy: A case report and a review of the diagnostic criteria and management proposal.

Human T-lymphotropic virus (HTLV) is considered to be the most highly oncogenic existing virus, being the cause of several fatal diseases such as adult T cell leukemia-lymphoma (ATL) and HTLV-I-associated myelopathy (HAM). The main transmission methods are unprotected sexual intercourse, vertical transmission and breastfeeding and direct exposure to infected blood or tissue. The identification of infected mothers prior to delivery is a highly important step in preventing mother to child transmission. Universal antenatal screening for HTLV is not recommended in Romania, although there are sufficient data demonstrating the risk of vertical transmission. We present the case of an HTLV-1-infected pregnant woman, with an aim to highlight: i) points of strategy for the management of HTLV during pregnancy; ii) the particularities of the course of pregnancy; and iii) the aspects that show the importance of knowing the status regarding the HTLV infection antepartum. The case was particular due to the ascendant proviral load during the pregnancy period, which led to the initiation of antiretroviral therapy and the particular pregnancy outcome with preterm rupture of membranes and fetal growth restriction. According to current recommendations, pregnant women infected with HTLV-1 should be advised to refrain from donating blood, body organs, or other tissues. There is no evidence of the number of individuals infected with this virus in Romania at present, and the diagnosis can only occur by chance. A specific treatment or immunization for HTLV infection does not currently exist, thus preventive methods are the only tool to reduce the prevalence and mortality of this infection.

Can Anorectal Atresia Be Diagnosed in the First Trimester of Pregnancy? A Systematic Literature Review.

Anorectal atresia (ARA) is a common congenital anomaly, but prenatal diagnosis is difficult, late, and unspecific. Utilizing a case of a 46 year old primipara with an egg donation In Vitro Fertilization (IVF) pregnancy, diagnosed at the first trimester scan with an anechoic isolated structure, which indicates anal atresia, we performed a systematic literature review in order to evaluate early prenatal ARA diagnosis. A total of 16 cases were reported as first trimester ARA suspicion, and only three had no associated anomalies. The most frequent ultrasound (US) sign was the presence of a cystic, anechoic pelvic structure of mainly tubular shape, or a plain abdominal cyst. In the majority of cases, structures were thin-walled and delimitated from the bladder. The presence of hyperechoic spots signifying enterolithiasis and peristaltic movements were helpful in order to establish the bowel origin of the lesion. Considering the high eventuality that the lesion is transitory, meaning later in pregnancy the fetus looks normal, early detection of such a sign should prompt further structural detailed evaluation, karyotyping, and appropriate pregnancy and postnatal counselling.

Subtotal Colectomy as Part of Debulking Surgery for Advanced-stage Ovarian Cancer.

BACKGROUND/AIM: The presence of extensive lesions of peritoneal carcinomatosis is found in a significant number of cases of extended digestive resection surgery, such as subtotal colectomy. The aim of this study was to report a series of 17 cases that necessitated performing subtotal colectomy as part of cytoreductive surgery for advanced-stage ovarian cancer. PATIENTS AND METHODS: Between 2012 and 2020 subtotal colectomy was associated as part of the debulking effort in 17 cases. RESULTS: The median age at the time of surgery was 59 years, while the initial stage at the time of diagnosis was IIIC in 14 cases, and respectively IV in three cases. Optimal debulking surgery was achieved in all cases. The continuity of the digestive tract was reestablished in 11 cases, while in the remaining 6 cases a terminal ileostomy was performed. CONCLUSION: Extended digestive tract resections may be needed in certain cases in order to maximize the debulking effort in patients with advanced-stage ovarian cancer.

The Influence of the Metabolic Syndrome on Early Postoperative Outcomes of Patients With Advanced-stage Endometrial Cancer.

BACKGROUND/AIM: Endometrial cancer is one of the most commonly encountered malignancies among obese women worldwide, a strong causality relationship being established between the two entities. Furthermore, obesity is also associated with metabolic syndrome; the aim of this study was to investigate the effect of metabolic syndrome on the postoperative outcomes of patients with endometrial cancer. PATIENTS AND METHODS: Data of 23 patients diagnosed with endometrial cancer and metabolic syndrome were retrospectively reviewed and compared to the those of a control group of patients diagnosed with endometrial cancer in the absence of metabolic syndrome. RESULTS: Patients in the first group presented significantly higher values of body mass index when compared to the control group. There were no significant differences in terms of stage, histopathological subtype or degree of differentiation between the two groups. The completeness of cytoreduction was lower among patients with metabolic syndrome, however, this did not reach statistical significance (p=0.08). Although the rate of complete debulking was lower among those with metabolic syndrome, the rates of postoperative complications were significantly higher. CONCLUSION: The association of metabolic syndrome significantly influences the risk of postoperative complications in patients with endometrial cancer; moreover, in certain cases, it might preclude the achievement of freedom from residual disease.

Utility of indocyanine green injection in patients with cervical cancer besides the identification of sentinel lymph node (Review).

Due to the wide introduction of screening tests, patients with neoplastic diseases of the uterine cervix trend to be diagnosed in early stages of the disease, and less invasive surgical procedures are needed in certain cases. In this respect, the technique of sentinel lymph node dissection has been widely implemented as part of the therapeutic strategy, indocyanine green (ICG) being one of the most reliable markers for sentinel lymph node detection. However, it seems that this agent is extremely useful in order to achieve better short-term and long-term results after cervical cancer surgery, due to its capacity to determine the uterine vascular perfusion in cases in which conservative treatment, such as trachelectomy, is performed, as well as to prevent and treat lower limb lymphedema. A literature review was conducted of the studies which focused on the role of ICG utility in cervical cancer patients besides sentinel lymph node detection, special focus was given to vascularization preservation and lower limb lymphedema prevention and treatment.

Reconstruction of superior mesenteric artery by prostheses placement in a case of chronic mesenteric ischemia: A case report and literature review.

Although superior mesenteric artery stenosis is a relatively common situation, it is rarely symptomatic due to the fact that in a significant number of cases an adequate collateral circulation exists. The aim of this study is to report a case in which arterial reconstruction was needed due to the absence of such a patent collateral circulation. The 47-year-old patient was investigated for chronic postprandial pain and was diagnosed with superior mesenteric artery stenosis. Percutaneous treatment was the initial option of choice but the patient rapidly became symptomatic again. Therefore surgery was performed, the segment of arterial stenosis was resected and the arterial continuity was re-established by using a synthetic prosthesis. The postoperative outcome was uneventful, the patient was discharged in the seventh postoperative day under anticoagulant therapy. In conclusion, superior mesenteric artery reconstruction by using a synthetic prosthesis can be useful in cases presenting chronic mesenteric ischemia and failure of percutaneous treatment.

Radical Hysterectomy for Cervical Cancer in Patients With Uterine Prolapse.

BACKGROUND/AIM: Association between cervical cancer and uterine prolapse represents a scarce eventuality. This is a case series of 11 patients diagnosed with different stages of cervical cancer in association with uterine prolapse. PATIENTS AND METHODS: Between 2014 and 2020, 11 patients were diagnosed with cervical cancer on prolapsed uterine cervix. RESULTS: The mean age of patients at the time of uterine cervix diagnosis was 68 years. In six cases, the first intent treatment was surgery, while in the remaining five cases it consisted of radio-chemotherapy, followed by radical surgery. The perioperative and postoperative outcomes were compared to those reported in a similar series of patients diagnosed in similar stages of the disease, but in the absence of uterine prolapse, no significant differences being encountered. CONCLUSION: Although it represents an unusual situation, malignant transformation of the uterine cervix might be encountered even in cases presenting uterine prolapse. In such cases, the therapeutic strategy should be tailored according to the stage of the disease.

Squamous Cell Carcinoma from Abscessed, Mature Cystic Ovarian Teratoma - A Case Report and Literature Review.

BACKGROUND/AIM: Malignant transformation of mature cystic ovarian teratoma is a scarce eventuality, only rare cases being reported so far. Furthermore, development of this transformation in the setting of an abscessed tumor is even scarcer. The aim of this study was to report the case of a 47-year-old patient submitted to surgery for such a lesion. CASE REPORT: The patient was investigated for diffuse pelvic pain and diagnosed with a 10×7×8 cm mass at the level of the left adnexa with imaging findings suggesting the presence of an ovarian teratoma. The patient was submitted to surgery involving a total hysterectomy with bilateral adnexectomy, lymphadenectomy and peritoneal biopsies. The histopathological examination demonstrated the presence of squamous cell carcinoma areas transformation in association with areas of abscess. Postoperatively the patient was submitted to six cycles of platinum-based chemotherapy and concurrent external radiotherapy. At one-year follow-up she is free of recurrent disease. CONCLUSION: Although malignisation of mature cystic ovarian teratoma is a rare event, it should not be omitted when mature ovarian teratoma is suspected; however, association between malignant transformation and abscess is a scarcer eventuality.

Debulking Surgery for Moderately Differentiated Neuroendocrine Gastric Carcinoma - A Case Report and Literature Review.

BACKGROUND/AIM: Gastroenteropancreatic neuro-endocrine carcinomas represent poorly differentiated neoplasms with a high capacity of spreading inducing the development of distant metastases. In such cases debulking surgery seems to offer a good chance for survival especially in well and moderately differentiated lesions. The aim of this study was to report the case of a 48-year-old patient submitted to surgery for moderately differentiated neuroendocrine gastric carcinoma with distant metastases. CASE REPORT: The patient was initially investigated for hematemesis and weight loss and was diagnosed with a lesser curvature gastric tumor in association with liver and peritoneal metastases. Due to the extent of the disease, the patient was initially submitted to neoadjuvant chemotherapy followed by surgery with radical intent. At the time of surgery subtotal gastrectomy en bloc with total omentectomy, peritonectomy, cholecystectomy and atypical liver resection were performed. Moreover, the two ovaries presented large tumoral masses so total hysterectomy with bilateral adnexectomy was performed. The histopathological studies confirmed the presence of a moderately differentiated neuroendocrine gastric carcinoma with negative resection margins. CONCLUSION: Multiple visceral resections might be needed in order to maximize the debulking effort in metastatic gastric neuroendocrine carcinomas.

Unexpected location of endometrial adenocarcinoma - a case report.

Endometrial adenocarcinoma (ADK) is one of the most common uterine cancer and the fourth neoplasia mortality cause in women according to the literature data. ADK is encountered in the sixth decade of life, the mean age being 63 years. Only 2-5% of cases are found in women less than 40 years old. We present the case of a 63-year-old woman admitted in our Clinic for hypogastric pain and reduced vaginal sanguinolent discharge. The genital examination and transvaginal ultrasound (US) scan were strongly suggestive for a type 0 myoma tending to be expelled through the cervical canal. Laparotomy and total hysterectomy with bilateral adnexectomy were performed. Histological examination identified a grade G1 well-differentiated endometrioid ADK without uterine wall invasion. The immunohistochemistry study for estrogen receptors expression revealed moderate and strong nuclear immunostaining in more than 70% of the tumoral cells, as well as a mosaic p16 immunoexpression, a cytokeratin 7 (CK7) immunophenotype, no p53 overexpression and low Ki67 index (estimated at 10-15%). Considering the incidental finding, the early stage and limited localization of the ADK at the myoma surface level surgery was considered sufficient as treatment but follow-up was conducted by magnetic resonance imaging (MRI) and general examination every six months. The most interesting aspect of the case was the atypical presence of an active myoma in menopause and the totally unsuspicious US appearance of the endometrium. The endometrial ADK was accidentally discovered in an unusual specimen without any other symptom.

Modern interdisciplinary monitoring of cervical cancer risk.

Currently, Romania ranks first in Europe with regard to cervical cancer mortality. A new solution proposed for optimizing cytology-based screening, before seeing the risk associated with minor abnormalities results, is the use of molecular markers. This study concerns atypical squamous of undetermined significance (ASC-US) results, the grey zone of cytology that hides up to 15% high-grade lesions, to see how dual immunocytochemistry (ICC) staining for p16INK4a∕Ki67 help to better identify and manage high-risk (HR) ASC-US patients. We included and reviewed 183 cases with ASC-US results and p16INK4a∕Ki67 double staining (DS) performed in MICOMI Clinic (Bucharest) during 2014-2016. All patients were referred for colposcopy and biopsy if appreciated as necessary and followed-up at six and 12 months. One DS(+)∕HR human papillomavirus (HPV) negative case was positive for HPV73 Group IIB International Agency for Research on Cancer (IARC). The mean age for ASC-US in our study group was 32 years, with a median of 31 years and 31% of patients were aged 25-29 years. The sensibility of p16INK4a∕Ki67 double immunostaining was 100%, the specificity 88%, the positive predictive value (PPV) was 82%, and the negative predictive value (NPV) was 100%. The use of p16INK4a∕Ki67 ICC test optimizes the medical approach towards screening or monitoring especially in ASC-US HR HPV(+) young patients, unnecessary colposcopies are avoided thus invasive gestures at nulliparous are limited.