[A rare case of giant leiomyoma in postmenopausal woman].

67 years old patient with huge abdominal tumor cardiovascular and respiratory failure is admitted urgently in hospital. Diagnostic difficulties posed by that case as well as surgical intervention for removal of 23kg leiomyoma are presented. After uneventful postoperative period the patient is discharged from hospital in good general condition.

[Cervical intraepithelial neoplasia: an attempt to propose rules for good medical practice].

The authors emphasize the advantages of the term "cervical intraepithelial neoplasia" (CIN) over "dysplasia" and "carcinoma-in-situ". The rules for good medical practice in treating CIN are based on several starting points, namely: proven role of the human papillomavirus (HPV) in the development of CIN; current possibilities to diagnose and to prevent HPV infections; morphological stigmata of CIN within the epithelium; possibilities to treat CIN and lack of possibilities to treat HPV infection; assessment of the patient 's reproductive potential. In recent cases of CIN1 the history of anti-HPV vaccination is an important factor in choosing the best treatment protocol. In cases of persistent CIN1 treatment protocols are influenced by the presence/absence of high-risk types of HPV. In recent cases of CIN2 treatment protocols vary according to the extent of the lesion, as well as its penetration within the cervical canal. The latter sign is of foremost importance in recent cases of CIN3. Treatment protocols for all the above mentioned conditions, for persistent CIN2 and CIN3,as well as for post-treatment recurrences are presented in flow chart form. Patients' age and reproductive potential should be taken into consideration in selected cases of CIN2+. CIN in pregnant patients deserves a more conservative approach.

[Cesarean scar ectopic pregnancy: diagnosis with 2D, three-dimensional (3D) ultrasound and 3D power doppler of a case and review of the literature].

Cesarean scar pregnancy is rare type of ectopic pregnancy. It is associated with severe complication if it is not diagnosed early in pregnancy. We present a case of difficult first-trimester diagnosis of Cesarean scar pregnancy. In this paper we discuss the incidence of this condition, the antenatal diagnosis, the prognosis and management and the importance of 2D and 3D ultrasound technique as a diagnostic tool.

[Radical colpoparametrectomy after simple hysterectomy--operative treatment of patients with invasive cancer of the uterine corpus and cervix].

INTRODUCTION: Diagnosis of invasive cervical carcinoma or residual tumor disease in patients who had previously simple hysterectomy means that the initial surgery is incomplete according to the oncological standards. One of the options in such cases is a second stage surgery--radical colpoparametrectomy (RC). MATERIAL AND METHODS: A retro- and prospective study during a period of Feb 1994-Jun 2010 enrolled a total of 28 patients that underwent RC after simple hysterectomy. Data were collected on demographics, tumor stage, histology, postoperative therapy, survival, complications. RESULTS: Median age of patients was 54.7 years. Invasive cervical carcinoma was diagnosed in 20 of 28 patients. Residual tumor disease was found in 5/28 patients who had simple hysterectomy for endometrial cancer. Uterine sarcoma was diagnosed in 3 cases. Histology revealed absence of tumor in 10/28 patients, lymph nodes, vaginal, and/or parametrial metastases in 18/28. Postoperative radiation and/or chemotherapy was arranged in 19/28 cases. Median follow up was 56 months with an overall 5-year survival of 88%. 11/28 patients had postoperative complications. CONCLUSION: RC is an alternative therapeutic approach for patients with invasive cancer of the uterine corpus and cervix who had simple hysterectomy.

[Laterally extended parametrectomy in cases with cervical carcinoma].

INTRODUCTION: Clinical staging of cervical carcinoma is not always an easy task, especially in cases with parametrial involvement, stage IIB. Therapeutic approach may differ in such patients- conservative (radio-, chemoradiation) therapy versus operative treatment. Research shows that the limits of the typical class III-IV radical hysterectomy may prove to be inadequate in relation to the dissection of the lateral parametria. A new surgical technique called laterally extended parametrectomy was published in 1993 and provides the means of total removal of the connective and lymphatic tissue up to the level of the true pelvic sidewall. MATERIAL AND METHODS: A retro- and prospective study was performed during the period between Jan 2008 and Feb 2011. A total of 17 radical hysterectomies with unilateral LEP were enrolled. Median age of patients was 51 years. Mean duration of surgery is 3 hours 57 min. Laterally extended parametrectomy was initiated in cases with clinically predetermined stage IB to II/IA cervical cancer. 3 patients were diagnosed with adenosquamous type of carcinoma, while the other 14 were with squamous cell cervical cancer. RESULTS: Positive iliac lymph nodes were found bilaterally in 7 patients, unilaterally also in 7 patients, while 3 cases proved to be negative. Paraaortic lymph node dissection was performed in 6 surgeries, with positive histology in 4 cases. Parametrial infiltration was found in 6 patients, 3 of them bilateral. 8 of the patients had unilateral hydroureter. CONCLUSION: Laterally extended parametrectomy is a surgical technique which provides the means for full removal of the lymphatics and connective tissue up to the pelvic sidewall, during radical hysterectomy in patients with cervical cancer, stage IB and IIA, with positive iliac lymph nodes, as well as in stage IIB cases. It offers an efficient alternative for surgical treatment of locally advanced cervical cancer, opposed to the other therapeutic approaches.

[Asymmetric obstructed uterus didelphys/incomplete Herlyn-Werner-Wunderlich syndrome/diagnosed by transvaginal 3D ultrasound--a case report].

Asymmetric obstructed uterus didelphys (Herlyn-Werner-Wunderlich syndrome-HWWS) is a rare congenital Müllerian anomaly consisting of uterus didelphys, hemivaginal septum and ipsilateral renal agenesis. We present a case of an incomplete HWWS diagnosed by 3D transvaginal ultrasound in a 22 year old patient with absence of the hemivaginal septum. The most contributive diagnostic factors as well as the appropriate therapeutic management in such cases are discussed.

Whole abdominal irradiation in endometrial cancer - a single institution study.

PURPOSE: To examine the use of whole abdominal irradiation (WAI) open field technique in patients with stage III endometrial cancer (EC). METHODS: Between 1993 and 2007, 26 patients (age 39-70 years, median 58) with stage III EC (IIIA 15, IIIB 2, IIIC 8) were treated with WAI after primary surgery. Five (21)) patients had grade 1 disease, 18 (67%) grade 2 and 3 (12%) grade 3. In 2 (8%) patients a second laparotomy was carried out before the radiotherapy (RT) referral. Ascites and positive peritoneal cytology was present in 3 (15%) and 4 (20%) patients, respectively. After surgery, residua < 2 cm in the upper abdomen were left in 2 patients. WAI was delivered using Co 60 anterior-posterior photon fields to encompass the peritoneal cavity. In 84% of the patients WAI consisted of 30 Gy, delivered mainly in daily fractions of 1.5 Gy (81%), 5 fractions per week. For the remaining patients the dose was 25 Gy (8%) and 20 Gy (8%), respectively. After abdominal RT, 85% of the patients were given a pelvic boost to reach 45 - 50 Gy with 1.8 Gy/fraction/day, using a Co 60 unit. In 5 (19%) patients boost to 45-50 Gy with 1.8 Gy/fraction/day to other risk sites was also given. Two (8%) of 26 patients received 2 cycles of platinum-based chemotherapy. The mean follow-up time was 13.41 years. RESULTS: The treatment time ranged from 14-74 days, median 48. The overall survival (OS) rate was 93% at 5, 10 and 14 years. Ten (38.5%) patients received their treatment with no interruption, and in 16 (61.5%) patients RT was transiently interrupted because of acute gastrointestinal and hematological toxicity. Neither grade 4 acute complications nor mortality while receiving treatment were observed. Late side effects (grade 2 gastrointestinal complications) developed in 1 (5%) patient. During the observation period a second primary malignancy was recorded in 1 patient. CONCLUSION: WAI achieves a quite favorable 5- and 14-year survival rate with an acceptable risk of acute and late side effects in properly selected patients with stage III EC. WAI as a sole or a part of combined treatment warrants further investigation in patients with high-risk EC.

[Effect of appendectomy as an etiological factor in tubal sterility]. / Znachenie na apendektomiiata kato faktor v etiologiiata na tubarniia sterilitet.

In our retrospective study we try to find out the correlation between appendectomy and development and severity of tubal sterility. We analyzed 342 HSG and the results of 210 following diagnostic laparoscopies. The results show direct connection between complicated appendectomy and the stage of development of tubal sterility.

Large post-hysterectomy and post-radiation vesicovaginal fistulas: repair by ileocystoplasty.

PURPOSE: We devised a technique for simultaneous closure of large post-hysterectomy and post-radiation vesicovaginal fistulas, and augmentation of the concomitant shrunken bladder by ileocystoplasty as a 1-step procedure. MATERIALS AND METHODS: Between 1989 and 2000, 4 patients with large vesicovaginal fistulas after radical hysterectomy and radiotherapy for spinocellular cancer of the uterine cervix underwent fistula repair according to the technique described. The premise of utmost importance in the proposed technique is a healthy and not radiation damaged distal ileum. RESULTS: Fistula closure was achieved in 3 patients, while in 1 a 3 mm residual fistula was repaired 5 years later by a Martius skin flap. In all patients the augmented bladder allowed good quality of life with spontaneous voiding, and daytime and nighttime continence. CONCLUSIONS: The technique described seems to have certain advantages. Wide dissection of the bladder from the vagina and pelvic walls is avoided. The bladder defect is closed with a well vascularized ileal segment. Bladder capacity is enlarged simultaneously with good functional results. The procedure can be adapted to cases with concomitant damaged distal ureters.

[Cervical cancer and pregnancy--diagnostic and therapeutic problems. Report of four cases and review of the literature]. / Rak na matochnata shiika i bremennost--diagnostichni i terapevtichni problemi. Suobshtenie na chetiri sluchaia s pregled na literaturata.

In this publication are presented four cases of pregnant women with a cervical cancer (with preoperative staging) as follow: the first pregnant 6-7 g.w., stage T1a1, No, Mo, the second 19-20 g.w., staged as T2a, Nx, Mo; the third--in 20-21 g.w., stage T1b2, Nx, Mo and the fourth in 29-30 g.w., with premature rupture of membranes and stage T1b2, Nx, Mo. To all patients was performed radical hysterectomy with pelvic lymphnode dissection, and to three of them followed by radiotherapy. To the first operation was performed after induced abortion, to the second hysterectomy was with a fetus in uterus, the third and fourth were with Sectio parva and Sectio caesarea, followed at the same time by radical hysterectomy. The different diagnostic and therapeutic approaches to pregnant women with a cervical cancer, depending of the stage of the disease, the term of pregnancy and the patient and physician's desire are discussed.

[Is the directed biopsy accurate?]. / Pritselna li e pritselnata biopsiia?

The aim of the present study was to evaluate the diagnostic accuracy of the colposcopically directed biopsy of cytologically signalized women. Retrospectively were analyzed sixty women aged between 20 and 69 (mean 37.4), to whom was performed colposcopically directed biopsy and consequent in the interval of no more than 3 months extended excision (to 30 of them--surgical conisation and to another 30--LLETZ/LEEP). Summarized data shows, that in 47 (78.3%) of them there are coincidence to one degree difference in the histological findings, and of the remain 13 cases--in 4 (6.7%) there are false positive results, and in 9 (15.0%)--false negative. The value of the sensitivity is 83% and of the predictive value of the positive results is 91.7%, which put them in the borders of the good performance of the diagnostic test. The conclusion is that the accuracy of the directed biopsy is determined by the presence or absence of the good correlation between cytological, colposcopical and histological investigation, as the implementation of the excisional biopsies enlarged the possibilities of the diagnostic protocol for the following adequate therapeutic action.

[Treatment of bacterial vaginosis with high dosage metronidazole and lactic acid]. / Lechenie na bakterialnata vaginoza s visokodoziran vaginalen metronidazole i mlechna kiselina.

INTRODUCTION: Bacterial vaginosis (BV) is one of the most frequent vaginal infections in women of reproductive age. This condition is a disbalance of vaginal flora that is expressed in a considerable displacement of normal lactobacilli flora by opportunistic and facultative microorganisms. Despite the moderate or missing clinical manifestation this dysbacteriosis is linked with many complications in obstetrics and gynecology. AIM: To evaluate the effect of treatment of bacterial vaginosis with the product Arilin rapid containing vaginal Metronidazole in high doses and a following vaginal application of lactic acid in a part of the patients. MATERIALS AND METHODS: For the period May 2001-August 2001, bacterial vaginosis was established in 45 patients of the Specialized hospital for active treatment in obstetrics and gynecology "Maichin Dom", Sofia and the Military medical academy-Sofia, gynecology ward. The diagnosis of bacterial vaginosis was established in accordance to Amsel's criteria and the results that were obtained from samples colored by Gram. For the treatment of BV were used local Metronidazole (Arilin rapid) and vaginal tablets containing lactic acid. The patients were divided into 3 groups. In the first group (18 women) vaginal suppositoria of 100 mg Metronidazole (Arilin rapid) were used for 2 days, in the second (20 women)--Arilin rapid x 1 glob./2 days and a following therapy with vaginal tablets containing lactic acid x 1 glob. for 7 days. The third group (7 women) was the control receiving placebo therapy--shampoo Dercome Femme containing lactic acid for external application. RESULTS: In the group receiving Arilin rapid we observed a normalization of vaginal flora in 71.43% (5/7), intermediate vaginal flora in 14.3% (1/7) and no change caused by therapy in 14.3% (1/7). In the second group, where lactic acid was included, cure was established in 94.1% (16/17) and in only one (5.9%) case was established intermediate vaginal flora. In the control group in 85.7% (6/7) of the cases was registered a lack of effect. CONCLUSION: Treatment with Arilin rapid showed good results in 71% of cases. Adding lactate to therapy improved the therapeutic effect and achieved cure in over 94%. The following application of vaginal lactate is an additional step helping the recolonisation of the vagina with lactobacilli and is a contribution to the struggle with recurrent forms.

[The immunological changes and prognosis of cholestatic jaundice in choledocholithiasis]. / Imunologichni promeni i prognoza na kholestatichnata zhultenitsa pri kholedokholitiaza.

Fifty-six patients presenting choledocholithiasis are covered by the study. They are distributed in groups according to total serum bilirubin values, as follows: with total serum bilirubin < 20 mumol/l--17; 20 to 50 mumol/l--13; 50 to 80 mumol/l--9; and > 80 mumol/l--17 cases. Sixty healthy, sex and age matched individuals serve as controls. The immunocompetent cells are determined flow cytometrically with FACS TAR (BECTON DICKINSON). A panel of monoclonal antibodies (Becton Dickinson) is used, including: Leu4 (anti-CD3+)--T-lymphocytes; Leu3a (anti-CD4+)--helper/inducer lymphocytes; Leu2a (anti-CD8+)--suppressor/cytotoxic cells; Leu11a (anti-CD16+)--cells with a natural killer activity; Leu12 (anti-CD19+)--B-lymphocytes. As shown by the obtained results there are no changes in cell-mediated immune response among choledocholithiasis patients with normal values of total serum bilirubin. Parallel to increasing the degree of cholestatic jaundice (ChJ) severity, the absolute values of lymphocytes and their subpopulations decrease. The deficit is most clearcut in patients presenting the highest degree cholestasis, as compared to healthy individuals ((Ly: 1690 +/- 174/2277 +/- 186; CD3+: 956 +/- 119/1793 +/- 67; CD4+: 607 +/- 83/988 +/- 80; CD8+: 239 +/- 52/639 +/- 85; CD16+: 146 +/- 38/367 +/- 55; CD19+: 181 +/- 33/200 +/- 13. In 11 cases with early restored biliary drainage (by the 21st day of ChJ), total serum bilirubin decreases within 10 days after the operation (choledochoduodenoanastomosis), whereas lymphocytes and their subpopulations show an increase in absolute values. Two months after choledochoduodenoanastomosis, the total serum bilirubin and the lymphocyte subpopulations being examined regain their normal values. In two instances with rather late biliary drainage recovery (30 days after ChJ) the total serum bilirubin and lymphocyte subpopulations under study show no tendency whatsoever towards normalization at 10 days postoperatively. The results of the study demonstrate that the poor prognosis among ChJ patients is also related to inhibition of the cell-mediated immune response. The early biliary drainage recovery (at 21 days of ChJ) exerts a more favourable effect on the immune system, and improves the prognosis of the clinical course run by the pathological process.

[The extrahepatic manifestations in hepatitis C virus (HCV) infection]. / Izvunchernodrobni proiavi pri infektsiia s khepatit C virus (HCV).

The hepatitis C virus (HCV) infection could affect not only the liver, but also other tissues, organs and systems. The number of the reported in the literature extrahepatic lesions by HCV incessantly increases. A reliable association between the infections by HCV and the mixed cryoglobulinaemias, membrano-proliferative glomerulonephritis and porphyria cutanea tarda is confirmed. The participation of HCV in the pathogenesis of some diseases of the thyroid gland, the lymphocytic sialadenitis, lichen planus, diabetes mellitus, thrombocytopenia, antiphospholipid syndrome, etc., is assumed. The extrahepatic lesions by HCV are probably connected with the participation of the immune system, but they may be as well due to the replicating virus in the affected tissues, organs and systems. The pathogenetic mechanisms of the extrahepatic and autoimmune manifestations of the infection with HCV are not elucidated, which poses difficult therapeutic problems regarding the choice of interferon and/or corticosteroid hormones.

[The systemic and local immune responses in patients with alcoholic liver cirrhosis depending on hepatitis C viral infection (HCV)]. / Sistemen i lokalen imunen otgovor pri bolni s alkokholna chernodrobna tsiroza v zavisimost ot infektsiiata s khepatit C-virus (HCV).

The systemic and local immune response was studied in patients with alcoholic liver cirrhosis and the significance of the combined infection with HCV. To investigation were submitted 23 patients (16 males and 7 females) aged between 29 and 61 years with alcoholic liver cirrhosis. Of them 14 were anti-HCV(+) and 9 anti-HCV(-). As controls were used 36 clinically healthy individuals, matched by sex and age to the patients. The flow cytometric analysis of the lymphocyte (Ly) populations from the peripheral venous blood and of cells from liver aspirate obtained by blind liver biopsy according to Menghini, was performed with FacsTAR (Becton Dickinson). In the anti-HCV(-) patients, as compared to the controls (patients/controls) the Ly subpopulations were increased: CD3+/mm3:2010 +/- 738/1440 +/- 388; CD4+/mm3:1350 +/- 441/991 +/- 442; IL-2R+/mm3:133 +/- 78.5/31 +/- 20. In the anti-HVC(+) patients we established increased IL-2R+/mm3: 170 +/- 126 as compared with the controls and anti-HCV(-) patients. The suppressor/cytotoxic (CD8+) Ly with their suppressor (CD8+CD11b+) and cytotoxic (CD8+CD11b-) subpopulations and natural killers (CD16+) had a tendency to diminution in the anti-HCV(+) patients. In both examined groups the B (CD19+) Ly were non-significantly increased. The flow cytometric analysis of the cells from the liver specimen in 9 patients of whom 3 anti-HCV(-) and 6 anti-HCV(+) revealed that CD3+ on the average were 32.8% +/- 20.4% (from 9.2% to 65.1%); CD4+ were 21.1% +/- 7.4% (from 12.0% to 34.5%); CD8+ 22.6% +/- 11.8% (from 4.7% to 39.8%) and their values were higher in the anti-HCV(+) patients; the correlation CD4+/CD8+ = 1/1.09 +/- 0.6; CD16+ were 12.9% +/- 10.1% (from 1.9% to 34.8%); CD19+ varied from 3.2% to 27.8%; monocytes (CD14+) were 7.69% +/- 5.65 (from 2.0% to 15.8%) from the cells of the aspirate and their percentage contents was higher in the anti-HCV(+) patients. The results of out study revealed that in patients with alcoholic liver cirrhosis changes in the cell immune response were also observed and that they were more marked in infection with HCV.

[The diagnostic value of dilatation and curettage in endometrial carcinoma]. / Diagnostichna stoinost na probnoto abrazio pri kartsinom na endometriuma.

The diagnostic accuracy of endometrial curettage is studied in 75 patients treated for endometrial cancer with respect to: 1. Detection of endometrial cancer; 2. Histologic type and grade of the cancer; 3. Spread to the cervical canal. It is found that: 1. The diagnosis of cancer by D&C is correct in 84% of cases; 2. The diagnosis of adenosquamous cancer is made by D&C in 25%; 3. Evidence of spread to the cervical canal by D&C is found in 24 cases and confirm ed by surgery in 7 (29.2%) cases, giving a false positive rate of 70.8%. Negative finding in py with target biopsy is advisable in cases of: 1. Positive cervical finding in the D&C specimen; 2. Negative finding in D&C specimen amd persisting symptoms.

[The demonstration of HPV DNA in cervical intraepithelial neoplasms and in invasive carcinomas of the cervix uteri by DNA-DNA in situ hybridization]. / Dokazvane na DNK na HPV v tservikalni intraepitelni neoplazii i v invazivni kartsinomi na matochnata shiika chrez DNK-DNK in situ khibridizatsiia.

Authors were applied a method of DNA-DNA in situ hybridization for demonstration of HPV 6, 11, 16 and 18 in cervical neoplasia and in invasion carcinoma of uterine neck. At 22 probes from CYV III and invasion carcinoma the results from hybridization with virus DNA were shown the presence of HPV-DNA at 15 patients. Some phases of method were optimized. Sensitiveness of method was controlled and compared with the results from the same probes, underlied to investigation with Southern-blot hybridization.

Detection of human papillomavirus DNA in gynaecological swabs by filter in situ hybridization.

Gynaecological smears from the endo- and ectocervix of women with and without cytological and colposcopic abnormalities of the epithelium were investigated for human papillomavirus (HPV) types 6, 11, 16, and 18 by filter in situ hybridization (FISH). The data were compared with cytological, colposcopic, and histological findings. Of the 266 gynaecological smears, HPV DNA was detected in 84 (32%); of 101 cytologically and colposcopically HPV negative cases, HPV DNA was found in 10%. Of 56 women, cytologically and colposcopically positive for HPV infection, HPV DNA was detected in 68%. The sensitivity of the method was controlled by comparing the results of FISH with those of Southern-blot analysis of five cervical tumour biopsies. The data presented demonstrate the necessity of FISH for identification of the HPV type that might be of prognostic value in cervical pathology. Cytological and colposcopic positivity is a reliable sign in about 70% of the cases where HPV infection was proved by FISH.