Does size matter? Retrospective analysis of large gynecologic tumors.

OBJECTIVE: To evaluate the characteristics of patients who underwent surgery due to the presence of a large pelvic-abdominal mass over a 5-year period in a university clinic. MATERIAL AND METHODS: Among 3476 gynecologic operations, intraoperative findings were evaluated retrospectively. Uterine and/or adnexal masses smaller than 20 cm were excluded to refine "large" tumors and 74 patients with large tumors were enrolled in the study group. Demographic characteristics, intraoperative findings, and results of histopathologic examinations were recorded. Moreover, preoperative and intraoperative findings were compared among tumors with adnexal origin according to their final histopathologic results. RESULTS: The mean age of the patients was 46 years. The most common symptom was abdominal pain, as recorded in 38 (51.4%) patients. Among all patients, 31 (41.9%) had coexisting illness and 13 (17.6%) had a history of surgery. The mean tumor diameter was 25.9±8.6 cm (20-60) and 60 (78.9%) tumors were of adnexal origin. The ratios of malignancy for large adnexal and uterine tumors were 34.4% and 12.5%, respectively. When the large adnexal tumors were re-evaluated, the mean cancer antigen (CA) 125 level was significantly higher, and ascites was more frequently detected in malignant tumors (p<0.01) then in benign and borderline tumors. CONCLUSION: Benign and borderline tumors are more common among large abdominopelvic masses, although the presence of ascites and elevated CA 125 may present malignancy in large gynecologic tumors. Further studies with larger sample sizes are needed to define the characteristics of large tumors and their malignant potentials.

Comparison Of Early-Stage High-Grade Serous Primary Fallopian Tube Cancers and Epithelial Ovarian Cancers: A Multicenter Study.

INTRODUCTION: We compared the disease free-survival (DFS) and overall survival (OS) rates of patients with high-grade serous primary fallopian tube cancer (HG-sPFTC) and high-grade serous epithelial ovarian cancer (HG-sEOC). METHODS: 22 early-stage cancer patients (International Federation of Gynecology and Obstetrics (FIGO) stages I-II) with HG-sPFTC were retrospectively evaluated. In addition, 44 control patients diagnosed with HG-sEOC were matched to these patients with respect to tumor stage at diagnosis. All patients underwent complete surgical staging, followed by adjuvant chemotherapy. Kaplan-Meier curves were used to generate survival data. RESULTS: The mean age of HG-sPFTC patients was 59.4 ± 6.2 years, and that of HG-sEOC patients 55.2 ± 11.0 years (p = 0.002). All patients underwent 6 cycles of platinum-based adjuvant chemotherapy. All operations were optimal. The 5-year DFSs were 77.3% for HG-sPFTC patients and 75% for HG-sEOC patients (p = 1.00).The 5-year OS rates were 81.8% in women with HG-sPFTC and 77.3% in those with HG-sEOC (p = 0.75). CONCLUSION: The DFS and OS rates of patients with early-stage (FIGO stages I and II) HG-sPFTC and HG-sEOC were similar. The surgical and adjuvant therapy management of these malignancies should be similar.

Sonographically guided core biopsy: a minimally invasive procedure for managing adnexal masses.

OBJECTIVES: We hypothesized that sonographically guided core biopsy is an effective method for the differential diagnosis of adnexal masses and evaluated patients who underwent core biopsies in our gynecologic oncology department. METHODS: We reviewed the medical records of 55 patients who underwent sonographically guided core biopsies in our gynecologic oncology department between 2010 and 2013. Patients with suspected ovarian malignancies who were unsuitable for optimal debulking surgery and patients at risk for higher morbidity and mortality because of a poor performance status, suspected nongynecologic tumors, and peritoneal tuberculosis were indicated for sonographically guided biopsy. RESULTS: The indications for sonographically guided core biopsy were candidacy for suboptimal cytoreduction (n = 32 [58.2%]), a poor performance status (n = 11 [20.0%]), and suspected nongynecologic tumors (n = 12 [21.8%]). Histopathologic evaluations revealed primary ovarian tumors in 36 patients (65.5%). Tuberculosis was found to be the second most common disease (n = 8 [14.5%]) among the patients who underwent core biopsies. In 2 patients (3.6%), histologic examination revealed metastatic colorectal cancer. CONCLUSIONS: Sonographically guided core biopsy may be preferred as a minimally invasive procedure for managing adnexal masses, particularly in patients with advanced ovarian cancer and high comorbidities who might benefit from neoadjuvant chemotherapy and in cases of suspected nongynecologic tumors, including pelvic tuberculosis.

Ruptured granulosa cell tumor of the ovary as a cause of acute abdomen in postmenopausal woman.

Acute abdomen with hemoperitoneum is a very rare entity in postmenopausal women due to gynecologic conditions. A 54-year-old, postmenopausal woman was brought to emergency department with severe abdominal pain. Physical examination revealed acute abdomen findings with 15 cm pelvic mass on the right adnexal region. Immediate exploratory laparotomy was performed. During laparotomy 1000 cc of bloodstained fluid, ruptured and actively bleeding large mass arising from right ovary was observed. Right salpingo-oopherectomy was performed in emergency conditions, and pathology report revealed an adult type of granulosa cell tumor. After this result, staging surgery was performed and patient was diagnosed as granulosa cell tumor stage 1 c. Cisplatin, etoposide, and bleomycin chemotherapy was given. Clinicians should be aware of granulosa cell tumors which may occur at any age and prone to rupture. Frozen section will be helpful in order to avoid incomplete surgeries especially in postmenopausal women presented with intra-abdominal bleeding.

Peritoneal tuberculosis mimicking ovarian cancer.

OBJECTIVE: To evaluate the characteristics of 20 patients diagnosed as tuberculous peritonitis (TBP) mimicking ovarian cancer during a 10-year period at a single center. STUDY DESIGN: Among 612 operations for ovarian malignancy we retrospectively reviewed the surgical and pathological reports of 20 patients suspected preoperatively as having ovarian malignancy but whose pathological results revealed TBP, between 2000 and 2011 in a university clinic. Demographic characteristics, physical and pelvic examination, laboratory investigations and radiological imaging of the patients were evaluated retrospectively. RESULTS: Diagnostic laparotomy, laparoscopy and ultrasound guided tru-cut biopsy were performed in 11, 2 and 7 of the 20 patients, respectively. The mean age of the patients was 37.5 ± 17.3 years (range 16-70 years). The most common symptoms were abdominal pain (n=14%, 70%) and abdominal distension (n=13%, 65%). Serum CA 125 was elevated in 16 (80%) cases and the average CA 125 level was 289 ± 186.2 IU/ml. During ultrasonographic imaging and CT scans, ascites and a pelvic mass were detected in 19 (85%) and 12 (60%) patients respectively. TBP was suspected in 7 (35%) patients and ultrasound guided tru-cut biopsy was preferred as a first-line approach. Surgery was performed in 11 patients (55%) and during exploration widespread miliary nodules (n=9%, 81%), widespread adhesion (n=5%, 45%), adnexal mass (n=8%, 72%) and caseous necrotic substance (n=4%, 36%) were observed. Patients underwent unilateral (n=3% 27%) or bilateral (n=4%, 36%) salpingo-oophorectomy in seven (63%) cases. CONCLUSION: Since ovarian cancer is a serious condition and preoperative diagnosis of TBP is difficult, laparotomy is usually mandatory to distinguish these two entities. Ultrasound guided tru-cut biopsy is useful in selected patients and frozen section analysis avoids hazardous radical surgery at operation.

PAP smear screening among married women living in Osamangazi University ALPU training area.

An inquiry including questions about socio-demographic and fecundity properties and covering the knowledge and attitudes of women about Pap smears was applied to 585 women living in Alpu district of Eskisehir, Turkey. Smear specimens were taken from 513 women and colpography was performed before and after acetic acid application with a digital camera. The women who had cervical lesions and/or aceto-white epithelium during the gynecological examination and/or had pathological findings in the smear and/or had suspicious findings at the colpography were invited (n=125, 24.4%) to the Department of Gynecology for colposcopic evaluation. Colposcopy was performed to 77 and biopsies were taken from 40 of the women during colposcopic examination. Of the biopsy specimens, 31 were accepted as benign while 9 were reported as pathology positive, one being high grade squamous intraepithelial lesion (HGSIL) and 8 low grade squamous intraepithelial lesion (LGSIL).

Pelvic organ prolapse complicating third trimester pregnancy. A case report.

The concomitant phenomenon of a third trimester pregnancy with a significant degree of pelvic organ prolapse is extremely rare. We report on a patient with pelvic organ prolapse complicating third trimester pregnancy treated by concomitant cesarean hysterectomy and abdominal sacrocolpopexy. A 30-year-old woman, gravida 6, parity 5, was admitted to the hospital with uterine contractions in week 35 of gestation. Pelvic examination in the dorsal lithotomy position revealed a stage 3 pelvic organ prolapse. A cesarean hysterectomy was performed. After hysterectomy, the vaginal cuff was suspended to the periosteum overlying the sacral promontory. Cesarean hysterectomy might be a therapeutic option for women who have completed their families and are suffering from severe pelvic organ prolapse complicating third trimester pregnancy, particularly in developing countries where access to health care is limited.

Uptake of 2-[18F]fluoro-2-deoxy-D-glucose in uterine leiomyoma: imaging of four patients by coincidence positron emission tomography.

Uterine leiomyomas, benign tumours of the human uterus, are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. As a functional imaging modality, 2-[F]fluoro-2-deoxy-D-glucose (F-FDG) positron emission tomography can be used to obtain information about glucose metabolism in tissues. In this study, the findings of the F-FDG scans of four patients who were suspected of having malignant gynaecological tumours because of clinical and radiological findings and finally diagnosed as uterine leiomyoma based on histopathological examination were evaluated. Moderately intense F-FDG accumulation was detected in uterine mass localization in lower pelvis. The reason for the accumulation of F-FDG in uterine leiomyomas is not known. It may be explained by the existence of higher levels of growth factors, including basic fibroblast growth factor, transforming growth factor beta, granulocyte-macrophage colony-stimulating factor and receptors, and proliferation of smooth muscle cells in leiomatous uterus.

Transvaginal ultrasonography and uterine artery Doppler in diagnosing endometrial pathologies and carcinoma in postmenopausal bleeding.

Routine dilatation and curettage (D&C) in all patients with postmenopausal bleeding (PMB) is debatable, as 70%-80% will eventually receive benign diagnoses. Endometrial thickness (ET) measurements by transvaginal ultrasonography (TVUS) are used with high sensitivity to detect patients who would benefit from D&C, yet they suffer from low specificity that fails to reduce undue invasive procedures. The aim of this study was to define optimal cutoffs for ET in diagnosing endometrial pathologies in PMB and to assess a possible complementary role for Doppler ultrasonography. The study population consisted of 97 women with PMB; 39, 22 and 36 of whom had endometrial cancer (EC), benign endometrial pathologies and normal endometrial findings, respectively, defined by D&C performed after TVUS, which was used to measure uterine dimensions and ET, together with pulsatility and resistance indices (PI and RI, respectively) of the uterine arteries. Receiver operating characteristics curves revealed ET to be the most valuable parameter to prognosticate both EC and any endometrial pathology (sensitivities of 90% and 89%, and specificities of 79% and 94% with optimal cutoffs of 9.6 and 7.7 mm, respectively). Binary logistic regression revealed uterine artery RI to be the only independent variable that could be used together with ET, which increased the sensitivity of ET to 97% and 93% for EC and any endometrial pathology, but caused its specificity to regress to 58% and 53%, respectively. Same levels of sensitivity, yet better levels of specificity of 60% and 89%, respectively, were attained by using a cutoff of 6.3 mm for ET alone. Assessing uterine artery Doppler indices has no complementary role for measuring ET in evaluating PMB.

Vaginal intraepithelial neoplasia: treatment by carbon dioxide laser and risk factors for failure.

OBJECTIVE: To evaluate the effectiveness of CO(2) laser ablation of vaginal intraepithelial neoplasia (VAIN) and to define prognostic factors. STUDY DESIGN: Medical records of 24 patients with VAIN II or III, treated by CO(2) laser ablation from 1990 to 1998 were reviewed. The grade, location, and focality of the lesions, the age, follow-up period and menopausal status of the patients, the power and duration of laser ablation, the presence of concurrent cervical or vulvar neoplasia or previous hysterectomy were evaluated as possible prognostic factors. RESULTS: Ablations of the VAIN were successfully accomplished in all of the patients with a mean period of 25.2+10.2 min, including additional simultaneous ablations of the cervix or vulva in eight (33.3%) patients. There was no early or late major complication. VAIN was completely eliminated in 17 (70.8%) patients after the first and in 19 (79.2%) patients after multiple episodes of ablation with a mean follow-up of 26.7+19.6 months. VAIN progressed to invasive vaginal carcinoma in one woman. None of the evaluated prognostic factors was found to be related to the persistence or recurrence. CONCLUSION: CO(2) laser ablation was a safe and effective method for the treatment of VAIN. However, since no prognostic factor was defined, all patients should be closely evaluated for persistence, recurrence or progression to invasion.

Assessment of gestational trophoblastic disease by Doppler ultrasonography.

OBJECTIVES: To relate uterine artery blood flow characteristics to serum human chorionic gonadotropin (hCG) levels in patients with gestational trophoblastic disease (GTD). STUDY DESIGN: Twenty-one patients with GTD were investigated by serum hCG titers and Doppler ultrasonography of uterine arteries. The relations between the Doppler indices and the serum hCG titers were evaluated by paired-t, Mann-Whitney U tests, and Pearson's correlation analysis. RESULTS: Significant but weak negative correlations were observed between systole/diastole (S/D) ratios, resistance indices (RIs) and pulsatility indices (PIs) and the absolute values of serum hCG levels with correlation coefficients of -0.31, -0.37, and -0.33 (P < 0.05). However, the same Doppler indices had more significant and strong negative correlations with the logarithmic values of the serum hCG levels with correlation coefficients of -0.65, -0.58, and -0.63, respectively (P < 0.01). Five patients who received chemotherapy had significantly lower Doppler indices than those 16 patients with spontaneous regression (P < 0.001). CONCLUSIONS: Uterine artery Doppler indices might be used for the surveillance of the patients with GTD.

A new ultrasonographic method for evaluation of the results of anti-incontinence operations.

BACKGROUND: To evaluate the effectiveness of a new ultrasonographic method for discrimination of successful and failed anti-incontinence operations. METHODS: Ninety-six patients who had undergone anti-incontinence operations for the diagnosis of pure genuine stress incontinence due to bladder neck hypermobility were evaluated by perineal ultrasonography and 1 hr standardized pad test 6, 12 and 24 months after their operations. The distances from the bladder neck to the lower tip (A) and to the posterior midpoint of symphysis pubis (B) were measured at rest and during stress. Bladder neck mobility (Mu) was obtained by two-caliper method. After superimposing the symphysis pubis of the frozen images, the bladder neck positions at rest and during stress were plotted on an x-y coordinate system by using computer programs and the corresponding x and y-values (X and Y) calculated and the second bladder neck mobility (Mc) were measured on the x-y coordinate system by computer. Unpaired and paired-t-tests were used for statistical analysis. RESULTS: Ten (10.4%) patients had recurrent urinary incontinence, while 86 (89.6%) were continent 24 months after the operation. The incontinent patients had significantly longer Mu, Mc and distance B during stress and lower X and Y-values during stress than the continent patients at the last control (P < 0.001). When the previous results were compared, the incontinent patients had significantly lower Y-values during stress and greater Mc values beginning 6 months after the operation, while they were still continent (P < 0.01). Once present, the significant differences between the incontinent versus continent patients persisted from that point onward. CONCLUSIONS: Measurement of the bladder neck mobility on an x-y co-ordinate system could discriminate the failed and successful operations and predict the outcome of the surgery.

Pedunculated uterine leiomyoma associated with pseudo-Meigs' syndrome and elevated CA-125 level: CT features.

A 38-year-old woman presented with a 1-week history of low back pain, distension, weakness, and loss of appetite. Laboratory studies showed a serum CA-125 level of 281 U/ml (normal value 1.2-32 U/ml). Abdominopelvic sonography revealed massive ascites, left pleural effusion, and a heterogeneous, hypoechogenic, and smoothly outlined solid mass. The mass had a close proximity and to the anterior side of the right ovary. Doppler sonography showed that the mass was hypervascularized. Computed tomography demonstrated numerous, tortuous vascular structures around the mass and along the omentum indicating its auxiliary vascularization from the omentum. Exploratory laparotomy and histopathological examination revealed pedunculated leiomyoma with parasitized blood supply from the omentum. Ascites and pleural effusion disappeared 6 months after surgery. We present the clinical and CT features of a parasitic leiomyoma adhering to the omentum.