Is aortic lymphadenectomy indicated in locally advanced cervical cancer after neoadjuvant chemotherapy followed by radical surgery? A retrospective study on 261 women.

OBJECTIVES: The aim of this study was to estimate the rate of aortic lymph nodes (LN) metastases/recurrences among patients affected by locally advanced stage cancer patients (LACC), treated with neoadjuvant chemotherapy (NACT) and radical surgery. METHODS: Retrospective evaluation of consecutive 261 patients affected by LACC (stage IB2-IIB), treated with NACT followed by radical surgery at National Cancer Institute, Milan, Italy, between 1990 and 2011. RESULTS: Stage at presentation included stage IB2, IIA and IIB in 100 (38.3%), 50 (19.2%) and 111 (42.5%) patients, respectively. Squamous cell carcinoma accounted for more than 80%, followed by adenocarcinoma or adenosquamous cancers (20%). Overall, 56 women (21.5%) had LN metastases. Four out of 83 women (5%) who underwent both pelvic and aortic LN dissection had aortic LN metastases, and all women had concomitant pelvic and aortic LN metastases. Only one woman out of 178 (0.5%) who underwent pelvic lymphadenectomy only, had an aortic LN recurrence. Overall 2% of women (5/261) had aortic LN metastases/recurrence. CONCLUSIONS: Our data suggest that aortic lymphadenectomy at the time of surgery is not routinely indicated in LACC after NACT, but should reserved in case of bulky LN in both pelvic and/or aortic area. The risk of isolated aortic LN relapse is negligible. Further prospective studies are warranted.

Secondary cytoreductive surgery for isolated lymph node recurrence of epithelial ovarian cancer: a multicenter study.

INTRODUCTION: Chemotherapy is the standard treatment of recurrent epithelial ovarian cancer (EOC), but its use in nodal relapses is still debated. On the other hand, the role of secondary cytoreductive surgery (SCS) remains controversial. Aim of this study is to evaluate feasibility and outcomes of SCS for the specific setting of recurrent ovarian cancer, exclusively relapsing in lymph nodes. PATIENTS AND METHODS: We conducted a retrospective analysis in five Italian Institutions (University of Torino, INT of Milano, CRO of Aviano, University of Pisa and INT of Napoli) from 2000 to 2012. Patients with EOC who underwent secondary surgery for isolated lymph node recurrence (ILNR) were selected. RESULTS: Seventy-three patients were identified. At first diagnosis, patients received debulking surgery and platinum-based chemotherapy. The median disease free interval from completion of primary chemotherapy to nodal recurrence was 18 months. Nodal recurrence was para-aortic in 37 patients (50.7%), pelvic in 21 (28.8%), pelvic and para-aortic in 9 (12.3%), pelvic and inguinal in 3 (4.1%) and inguinal in 3 (4.1%). During SCS, in 1 patients nephrectomy was necessary for renal vein injury. No significant postoperative morbidity occurred. Median follow-up is 50 months. After secondary surgery, 32 (43.8%) are alive without disease, 18 (24.6%) are alive with disease and 23 patients (31.5%) are dead of disease. Five-year overall survival from the time of treatment of recurrent disease is 64%. CONCLUSIONS: Secondary surgery for ILNR of ovarian cancer is feasible, safe, with low morbidity and it is associated with a favorable outcome.

A new approach in the first-line treatment of bacterial and mycotic vulvovaginitis with topical lipohydroperoxides and glycyrrhetic acid: a comparative study.

UNLABELLED: PURPOSE OF INVESTIGATIONS: The aim of this randomized controlled trial was to evaluate efficacy and tolerability of a new association of lipohydroperoxides and glycyrrhetic acid on topical treatment of bacterial and mycotic vulvovaginitis. METHODS: One hundred consecutive patients with bacterial or mycotic vulvovaginitis were randomly assigned to a study group treated with vaginal lipohydroperoxides and a derivative of glycyrrhetic acid for three days (n = 50), and a control group using vaginal antibacterial metronidazole (500 mg) or antimycotic econazole (150 mg) for six days (n = 50). RESULTS: A clinical and microbiological response was achieved in 80.4% and 88.9% in investigational and control group, respectively (p > 0.05). Compared to traditional antimicrobial drugs, the effect appears to be faster and safer, even if not significantly. The 6-month recurrence rate was 7.7% and 5.6% in the investigational and control group, respectively. CONCLUSION: Topical medication based on lipohydroperoxides and glycyrrhetic acid showed a clinical and microbiological efficacy in the first-line treatment of bacterial and mycotic vulvovaginitis, comparable to conventional drugs.

Serum osteoprotegerin correlates with age and bone mass in postmenopausal, but not in fertile age women.

PURPOSE OF INVESTIGATION: Osteoprotegerin (OPG) and receptor activator of nuclear factor kappaB ligand (RANKL) are bone turnover modulators expressed by osteoblasts. The aim of this study was to assess the relationship between the circulating OPG/RANKL system, age and bone mass, in fertile age and postmenopausal women. METHODS: In this cross-sectional observational study on 48 patients (fertile age, n = 22; postmenopause, n = 26), we investigated the correlation between serum OPG and RANKL, age and bone mineral density (BMD). Serum concentrations of OPG and RANKL were determined by enzyme-linked immunosorbent assay (ELISA); estimate BMD evaluation was performed with heel quantitative ultrasonometry (QUS). RESULTS: Serum OPG significantly increased (p = 0.003) and serum RANKL significantly decreased (p = 0.002), in the postmenopausal group compared to fertile age women. A significant correlation of serum OPG with age (r(s) = 0.39, p = 0.047) and BMD (r(s) = 0.45, p = 0.023) in postmenopausal women, and between RANKL and BMD (r(s) = 0.48, p = 0.024) in fertile age was found. CONCLUSION: These data demonstrate in vivo that the OPG/RANKL system is significantly associated with menopausal status and could play a role in postmenopausal osteoporosis.

Perineal ultrasound evaluation of urethral mobility after the TVT-O procedure.

AIMS: The aim of study was to assess, by means of perineal ultrasound (US), women treated with the trans-obturator suburethral sling procedure for urinary stress incontinence (USI). METHODS: Twelve women with USI and urethral hypermobility were enrolled. Static and dynamic perineal US of urethral mobility was performed before and after tension-free vaginal tape opturator (TVT-O) procedure: US parameters evaluated were pubis-urethra distance and inclination angle of the urethral axis. RESULTS: The Valsalva stress US evaluation showed a return to normal range of the pubic urethral distance in all cases (p = 0.0001); also a correction of the angle of inclination of the urethral axis occurred in all patients (p < 0.0001). CONCLUSIONS: Our results propose the use of perineal US for patients with USI as an additional diagnostic tool and a means for postsurgical follow-up.

[Endometrial survey during phytoestrogens therapy in postmenopausal women]. / La sorveglianza endometriale in corso di terapia con fitoestrogeni in postmenopausa.

AIM: The aim of this study was to verify the effects on endometrium of short-term phytoestrogens therapy in postmenopausal women. METHODS: This randomized study compared two groups of 50 patients undergone respectively to phytoestrogens therapy or placebo. An endometrial survey was performed on the study groups by ultrasound and hysteroscopy at baseline and at 6 and 12 months. RESULTS: The ultrasonographic findings and the hysteroscopic biopsies in the 47 women submitted to phytoestrogens therapy that completed the follow-up showed an atrophic and/or inactive endometrial mucosa less than in one patients (2.1%) with endometrial thickness and proliferative endometrium bioptical sample after 12 months of treatment; no cases of endometrial hyperplasia were found. CONCLUSION: In the authors' 12 month experience, phytoestrogens therapy in postmenopausal women was safe for endometrial stimulation because did not cause any significant alteration of the mucosa in a short-term administration.

Endometrial metastasis of a primitive neuroendocrine ovarian carcinoma: management and treatment of a case.

BACKGROUND: Neuroendocrine tumours are a heterogeneous group of separate clinico-pathological entities which have a common characteristic, i.e., expression of potential endocrine differentiation. In the ovary, the term "neuroendocrine" relates mainly to widely known carcinoids, but it may also be applied to rare neuroendocrine carcinomas as non-small cell type and small cell carcinomas of pulmonary type. In the literature only 11 cases of primary ovarian non-small cell neurendocrine carcinomas have been described and ten of these were associated with a surface epithelial ovarian tumour. Small cell neuroendocrine carcinoma of the ovary is a rare malignant tumour of the ovary. Advanced small cell carcinoma of the ovary is a very aggressive tumour with an overall poor prognosis and unfavourable outcome. CASE REPORT: The case reported is unique in the literature because the authors describe a rare case of endometrial metastasis of a primary ovarian non-small cell neurendocrine carcinoma without any surface epithelial ovarian tumour association. The tumour invaded up to less than half of the myometrium. The first symptoms were related to endometrial metastasis as metrorrhagia and pelvic pain while the asymptomatic presence of primary ovarian carcinoma was not acknowledged with physical examination, routine biochemistry, tumour markers, blood count and traditional transvaginal greyscale ultrasound. CONCLUSION: Magnetic resonance and three-dimensional (3D) ultrasonography with power Doppler are a great help in the diagnosis of ovarian localisation but only immunohistochemistry on histological material can provide a correct diagnosis. Immunohistochemistry expression of Ki67 is a useful marker of malignancy. Due to the rarity of this neoplasm, a general consensus for optimal treatment has yet to emerge. The reported biological aggressiveness of these tumours prompts combined treatment with radical surgery and adjuvant polychemotherapy.

Therapeutic alternatives in Behçet's syndrome.

Behçet's Syndrome (BD) is a chronic, relapsing, recurrent systemic vasculitis with an unknown cause. The disease affects all organs of the body concurrently or consecutively. Its various clinical manifestations result from ubiquitous small-vessel vasculitis, which is the underlying pathology. An Italian study has reported an increased association of the extended haplotype B51-DR5-DQw3. Without a known etiology BD syndrome has no uniformly acceptable therapy. Our study addresses therapeutic alternatives for the treatment of BD, with the systemic use of interferon alpha-2a., which has antiviral. immunomodulatory, antiproliferative, and antitumoral properties. Ten patients diagnosed with BD were referred from September 2002 to September 2005 to the Department of Gynaecology, Obstetrics and Reproduction of the Second University of Naples. The International Study Group (ISG) Criteria for Behçet's Disease (27) was applied. Patients were treated with oral prednisone; sulfasalazine; clobetasol; and interferon alpha-2a. Every month all patients had a complete blood count, platelet count, and liver function test. Biopsies of genital ulcerations identified small vessel vasculitis with mononuclear cell and lynphocytic infiltrates. HLA-B27 and B5 were positive in three subjects. The pathergy test was positive in all patients. Today the therapy is still ongoing, and none of the patients in therapy with our protocol present clinical symptoms of BD or intolerance. Laboratory findings are in a normal range and none have had neurological failure. Our findings may be attributable to less severe disease in a patients, to our smaller number of patients, or to other unknown factors. Nonetheless, these findings remain to be confirmed in a larger number of patients.

A rare case of female pelvic mass: angioleiomyoma of the broad ligament.

Angioleiomyoma is a benign mesenchymal neoplasm composed of smooth muscle cells and thick-walled vessels. It is usually found in the skin of the lower extremities. Angioleiomyoma is a very rare tumor among the ever-expanding repertoire of growth variants described in benign uterine leiomyoma. More rare is a solitary tumor of the broad ligament. Thus angioleiomyoma of the broad ligament is an extremely rare benign tumor of the female pelvis. In this report a 52-year-old woman with a one-year history of abdominal pain was admitted to our hospital. Gynaecological and ultrasonography exams showed a large mass with increased vascularization in the right adnexal region. The patient underwent total hysterectomy and bilateral salpingo-oophorectomy. The site of the benign mass was the left broad ligament of the uterus. On pathologic examination of the specimen, the tumor was diagnosed as angioleiomyoma. We present a case of angioleiomyoma of the broad ligament because of its extreme rarity and the large size of the tumor.

Modulation of apelin and APJ receptor in normal and preeclampsia-complicated placentas.

Apelin is an endogenous ligand of the human orphan receptor APJ. This peptide is produced through processing from the C-terminal portion in the pre-pro-protein consisting of 77 amino acid residues and exists in multiple molecular forms. Although the main physiological functions of apelin have not yet been clarified, it is known that apelin is involved in the regulation of blood pressure, blood flow and central control of body fluid homeostasis in different organs. Since human placenta is a tissue where vasculogenesis, blood pressure and flow are dramatically important to allow a normal embryonic and fetal growth and development, the aim of the present study was to investigate the immunohistochemical distribution of apelin and APJ in normal placentas throughout pregnancy and in preeclampsia-complicated placentas. Specifically, we observed that in normal placentas the expression levels of apelin decreased from the first to the third trimester of gestation in both cytotrophoblast and syncytiotrophoblast cells and in the stroma of placental villi, in contrast with increased expression levels of APJ in the cytoplasm of cytotrophoblast cells and in the cytoplasm of endothelial cells of normal placenta samples. In contrast, in preeclampsia-complicated pregnancies, we observed a very strong increase of expression levels of both apelin and APJ receptor in all the placental compartments, cytotrophoblast, syncytiotrophoblast and stroma with a particular increase in endothelial cells inside preeclamptic placental villi. Our data seem to indicate an important role of apelin and APJ in the regulation of fetal development through a correct regulation of human placenta formation during pregnancy. Moreover, the strong expression levels of apelin and APJ in preeclamptic placentas, suggest their possible involvement in the onset of this pathology.

Surgical approach to appendiceal mucocele mimicking an adnexal complex mass: case report.

Mucocele of the vermiform appendix is a rare disease of the appendix caused by mucoid substance retention in its lumen, due to obstruction or hyperproduction due to appendiceal retention cysts, mucosal hyperplasia, mucinous cystadenomas and cystadenocarcinomas. Therefore, also appendiceal malignancy can be the underlying cause, making accurate preoperative diagnosis imperative, even if this disease is often asymptomatic and an early diagnosis still remains very difficult on imaging studies. In women, appendiceal mucoceles can sometimes present on clinical and instrumental findings as a right adnexal mass mimicking an ovarian neoplasm. A rare case of appendiceal mucocele in a 36-year-old women with a right-sided painful pelvic mass is presented. The mucocele was misdiagnosed as a cystic complex mass of the right adnexa both clinically and ultrasonographically. Serum levels of CEA and CA19-9 were increased. Explorative laparoscopy was performed revealing an enlarged vermiform appendix with the uterus and adnexa macroscopically normal, and no signs of intraperitoneal metastasis or adnexal torsion. Laparotomic appendectomy followed. Histological examination revealed a mucinous cystadenoma of the vermiform appendix. This clinical entity of appendiceal mucocele should always be considered by gynaecologists as well as gastroenterologists in the differential diagnosis of patients presenting a right-sided adnexal mass on ultrasound in order to choose the best surgical approach.

A therapeutic algorithm for early-stage endometrial cancer: indications, patient selection, and feasibility.

Endometrial cancer is the most widely spread gynaecologic neoplasm in industrial countries. Mode of spread includes direct extension, lymphatic and haematic diffusion. Lymphatic involvement, particularly, is a topic of wide debate due to the strong therapeutic implications associated with it. In this regard, anatomic-surgical staging is better in that it corresponds to real conditions whereas clinical-instrumental staging is still today incomplete.

Alcohol sclerotherapy: a new method for Bartholin gland cyst treatment.

AIM: Bartholin gland cysts are one of the most common gynecologic problems. Around 2% of women suffer from these pathologies. Bartholin gland cyst are generally asymptomatic, but sometimes extremely painful to restrict physical activity. The treatment choice is related to the patient's age, the size of the cyst or abscess and relapses, but different approaches are possible. The aim of this study is to investigate the efficicacy and safety of the alcohol sclerotherapy versus the only aspiration to cure symptomatic cysts or abscesses of the Bartholin's gland. METHODS: Between January 2002 and June 2004, 18 patients suffering from Bartholin symptomatic unilateral cysts or with abscess are selected. These patients have been divided into 2 groups and they have been treated with alcohol sclerotherapy or aspiration. The simple aspiration removes only the cyst fluid. The alcohol sclerotherapy allows to destroy the epithelial covering of the cyst by a coagulative necrosis and then a fibrosis which covers the cavity and prevents the reformation of liquid. RESULTS: Treatment has been satisfactory for all the patients, and treatment time has been shorter with alcohol sclerotherapy. None of the patients, in both groups, presented sexual dysfunctions or dyspareunia. CONCLUSIONS: Alcohol sclerotherapy might be an ideal and safe procedure in the treatment of the Bartholin's gland or abscesses with a low percentage of relapses.

Third stage ovarian carcinoma--case report: the necessity of a multidisciplinary approach to treatment.

Ovarian carcinoma, part of a heterogeneous group of tumours, is the main cause of death by gynaecological neoplasms. The diagnosis, in general, is delayed. Multiorgan diffusion, the necessity of a surgical operation and strong chemotherapy, and the eventual pathology due to patient age are all factors that require a multidisciplinary approach. In fact the case, here reported, refers to a patient who came under our observation for a bilateral ovarian mass discovered casually during an abdominal ultrasound exam carried out for renal colic. Excellent cytoreduction with peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy (Figure 2), bilateral pelvic lymphadenectomy, total omentectomy, removal of nodules from the mesentery, the colon and three nodules in the abdominal wall thickness was executed. The histological report was G3, angioinvasive bilateral ovarian endometrioid adenocarcinoma. Metastasis was found only in one left obturator lymph node out of 17 lymph nodes removed. All of the removed abdominal, mesenteric and intestinal nodules were neoplastic. It is concluded that the complexity of similar cases always requires a multidisciplinary approach as in our case, involving an oncologist, hematologist, surgeon, gynaecologist, radiologist, anaesthesiologist, and nursing staff in the management of third stage ovarian cancer patients to obtain the best treatment thus guaranteeing a higher survival rate and better quality of life.

Local estrogen replacement therapy in postmenopausal atrophic vaginitis: efficacy and safety of low dose 17beta-estradiol vaginal tablets.

PURPOSE OF INVESTIGATION: To verify the effectiveness and safety of low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis. PATIENTS AND METHODS: 325 postmenopausal women with atrophic vaginitis in estrogenic replacement therapy with 0.025 mg 17beta-estradiol vaginal tablets, one application each day for two weeks, and a single application two times a week for the following 22 weeks (total treatment period: 24 weeks). RESULTS: Most of the women reported an improvement of symptoms just after two weeks and minimal incidence of adverse reactions. No patients showed abnormal endometrial thickness and no one had to interrupt the treatment for abnormal uterine bleeding because of systemic absorption. CONCLUSION: Low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis constitutes an extremely valid approach in terms of effectiveness and safety.

Methotrexate treatment for tubal pregnancy. Criteria for medical approach.

AIM: The purpose of this retrospective study is to underline the indications for the use of systemic methotrexate (MTX) in tubal pregnancies. METHODS: One hundred and four (n=104) consecutive women were treated in our Department for tubal pregnancy. The database analysis showed that after careful respect for inclusion criteria, the treatment chosen was the intravenous administration of MTX in 68 patients, whereas laparoscopy constituted the primary treatment in 36 patients. A single dose of MTX was intravenously administered, diluted in saline solution, with a dosage of 50 mg/m2 of body surface. Close serum beta-hCG monitoring was performed, and in the case of a short fall, a 2nd dose of methotrexate was submitted. RESULTS: The overall success rate of MTX treatment was 91%; the 2nd dose of MTX was used in 12% of patients, whereas in only 6 out of 68 patients included in the medical treatment group a surgical approach for suspected tubal rupture was necessary. CONCLUSION: Treatment with methotrexate is effective and safe in the presence of these criteria: patient hemodynamically stable, absence of tubal rupture sign and hemoperitoneum, an adnexal mass with a diameter < or = 5 cm, an amenorrhea < or = 6 weeks and HCG levels < or = 10,000 mIU/ml. Laparoscopy is indicated in diagnostic uncertainty, when MTX is not suggested, when adnexal mass is > 5 cm, or in patients in which beta-hCG levels was > 10,000 mIU/ml.

Alcohol sclerosis of endometriomas after ultrasound-guided aspiration.

AIM: We investigate the possibility to use ultrasound-guided aspiration and alcohol sclerosis in patients with endometrioma. METHODS: Ten patients with endometriotic ovarian cysts, mean diameter <70 mm, CA125 <35 UI, persistence of cyst after medical therapy and refusal of surgical therapy have been studied. The patients were submitted to ultrasound-guided aspiration of endometriomas. Fifty per cent of aspirated fluid was replaced with pure ethanol, which was left in situ for 10 to 20 minutes. No medical therapy was employed after aspiration and ethanol treatment. RESULTS: In 9 patients no recurrence was observed at ultrasound after 21.2+/-6.62 months of follow-up. In 1 case only, after 6 months, a recurrence of the endometrioma in the same site was observed. CONCLUSION: Ultrasound-guided alcoholic sclerotherapy of the endometriotic ovarian cysts is effective and safe. We speculate that this procedure could be indicated in patients refusing standard surgical therapy.