Uterobrush method in the detection of endometrial pathology.

BACKGROUND: Endometrial brush cytology is a widely accepted method for the detection of endometrial lesions. The aim of this study was to evaluate the role of cytological sampling using Uterobrush in the screening of endometrial pathology. PATIENTS AND METHODS: This is a prospective double-blind study evaluating the efficacy of the Uterobrush method (Cooper Surgical, Trumbull, USA) in the detection of endometrial abnormalities. Endometrial cytology was performed during the period January 2009 to April 2010 in all symptomatic patients that underwent dilatation and curettage. The collected samples were firstly smeared directly onto a glassslide and consequently into Thin-Prep buffer. Cytologic features were evaluated according to the criteria of Tao. The main objective was to evaluate the efficacy of Uterobrush method comparing the results of cytologic and histopathologic examination. RESULTS: The sample of the study consisted of 100 women aged 55.8 years (range 38-78 years) with recorded data regarding Uterobrush test and classic histologic examination. Fifty-five patients were postmenopausal. A total of 92% of the samplings were performed by trainees. Endometrial carcinoma was cytologically diagnosed in 8/9 patients, whereas endometrial polyps were diagnosed in 5/34 patients (14.7%). All the patients with simple hyperplasia were correctly diagnosed with the Uterobrush method, whereas the diagnosis of complex hyperplasia with or without atypia was correct in 85.7% and 100% of patients, respectively. Regarding endometrial carcinoma, the sensitivity, specificity, positive and negative predictive values were 88.9%, 100%, 100% and 98.9%, respectively. On the other hand, regarding endometrial polyps, the sensitivity, specificity, positive and negative predictive values were 14.7%, 100%, 100% and 69.5%, respectively. CONCLUSION: Uterobrush is a reliable direct intrauterine sampling for detecting endometrial abnormalities especially endometrial carcinoma and hyperplasia, but not endometrial polyps. It is a well-tolerated, easy to use method, which provides generous endometrial sampling without contamination from the endocervix or the vagina.

Evaluation of the paclitaxel-ifosfamide-cisplatin (TIP) combination in relapsed and/or metastatic cervical cancer.

BACKGROUND: Recurrent or metastatic cervical cancer represents an aggressive malignancy with a high rate of locoregional and distant failure. Therefore, we evaluated the three-drug combination of paclitaxel-ifosfamide-cisplatin (TIP). METHODS: Systemic chemotherapy-naive patients with advanced metastatic/relapsed cervical cancer and a World Health Organization (WHO) performance status (PS) of 0-2 were eligible. TIP chemotherapy doses were paclitaxel 175 mg m(-2) on day 1, ifosfamide 2.5 g m(-2) on days 1+2, and cisplatin 40 mg m(-2) on days 1+2, with prophylactic granulocyte-colony stimulating factor. RESULTS: A total of 42 patients with recurrent/metastatic cervical cancer are evaluable for response and toxicity: median age: 56 (25-74) years; PS: 1 (0-2); histologies - squamous: 35, adenosquamous: 5, and adenocarcinoma: 2. Responses were overall response rate (RR): 62% (95% confidence interval (CI): 47.3-76.7%), with complete response (CR): 26% (95% CI: 12.7-39.3%), and partial response (PR): 36% (95% CI: 21.5-49.9%). Responses according to the relapse site were overall RR: 32% (95% CI: 13.7-50.3%) within previously irradiated pelvis vs 75% (95% CI: 57.7-92.3%) in extra-pelvic sites. Median time to progression (TTP) was 7 (range, 2-34+) months and median overall survival (OS) was 16.5 (range, 3-36+) months. Toxicities included grade 3-4 neutropenia: 83% (21% febrile neutropenia), grade 3-4 thrombocytopenia: 9%, no grade 3 neuropathy (35% grade 2), grade 2 asthenia/fatigue 15%, and no treatment-related deaths. CONCLUSION: TIP is an active regimen with acceptable toxicity in advanced/relapsed cervical cancer.

Evaluation of the possible benefits of post-radiotherapy surgery after concomitant chemoradiotherapy with a new radio-sensitizing regimen (irinotecan / CPT-11, interferon A2b and amifostine) for advanced-stage cervical carcinoma. Preliminary results of a pilot phase-II study.

PURPOSE: This phase II pilot study was conducted to evaluate the results of a three-modality approach (which included post-chemoradiotherapy surgery) in advanced-stage cervical carcinomas. PATIENTS AND METHODS: Thirty-six patients underwent either surgery or were put on follow-up after having received radical cervical radiotherapy (RT) combined with radiosensitizing chemoimmunotherapy with irinotecan (CPT-11), interferon (IFN) A2b, and amifostine. The last selection (surgery or follow-up) was based on clinical evaluation (downstaged or not). Feasibility, morbidity, surgical outcome and survival were evaluated. RESULTS: Twenty-six patients had stage IIb and 10 IIIb disease at diagnosis. Sixteen (44%) were clinically downstaged, thus becoming eligible for surgery. Twelve (33%) were operated and the others were put on follow-up. There was no significant increase in treatment-related morbidity of the group of patients receiving three-modality therapy, since only one intraoperative complication had occurred. In 58% of the operated patients, chemoradiotherapy-resistant tumor was found on pathology of the cervical specimens, while 29% of them had lymph nodes infiltrated by the tumor. After a median follow-up of 42.5 months, overall survival (OS) of operated vs. non-operated patients (88 vs. 56%, respectively) show only a trend toward significance (p=0.10). The overall recurrence/metastasis rate was 36.1% and the disease-free survival (DFS) 56% for operated vs. 76% for non-operated patients, respectively (p=0.63). CONCLUSION: These results indicate that post-chemoradiotherapy surgery is justified because of the high rate of residual disease found. Morbidity can be effectively limited with proper patient selection. A considerable survival benefit is expected, although this remains to be confirmed with phase III studies.

Management of large retroperitoneal lipoma in a 12-year-old patient.

Retroperitoneal lipomas are rare tumors. The etiology of their proliferation is uncertain. Metabolic and genetic causes have been reported. We present the case of a 12-year-old patient with a large pelvic lipoma causing dysuria and pelvic pain. Magnetic resonance imaging revealed the existence of a large retroperitoneal fat tumor. Ultrasound-guided fine needle biopsy was performed to exclude malignancy. The biopsy specimen revealed tissue consistent with a benign lipoma tumor. Exploratory laparotomy revealed a solid lipoma of the retroperitoneal space 8 x 6 cm and weighing 300 g. The patient had a good postoperative performance status. Lipomas should be considered in the differential diagnosis of a solid tumor in the retroperitoneal space.

A two eterochronous primary gynaecological malignancies of different origin.

AIM: The objective of our study is to present a rare case of two eterochronous primary gynaecological malignancies. CASE: A 65-year-old para-2, white obese female, presented in our department 4 years ago, due to a single event of vaginal spotting. Curettage revealed an endometrial cancer. A total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Histology showed an endometrioid adenocarcinoma of endometrium stage Ib, moderately differentiated. No additional therapy was given. Twenty seven months later, a pathologic Papanicolaou smear came out on her routine follow-up. Although, recurrence on vaginal cuff was possible, the biopsies of anterior vaginal wall showed a poorly differentiated squamous cell carcinoma of the vagina. An exploratory laparotomy was performed, but tumor resection was not possible. The patient was classified as stage II vaginal carcinoma and underwent complete radiotherapy and chemotherapy. CONCLUSION: This case indicates that female genital carcinomas of different histological origins may occur with minimal time-interval, even in the absence of known predisposing factors like previous chemo-radiotherapy, HPV infection or diethylstilbestrol exposure. The role of close follow up of hysterectomised patients should also be mentioned (Fig. 1, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Primary peritoneal serous papillary carcinoma: clinical and laboratory characteristics.

BACKGROUND: Primary peritoneal papillary serous carcinoma (PPPSC) is an uncommon primary malignancy of the peritoneum. The aim of our study is to present the characteristics of such a rare entity through our case series. METHOD: This is a retrospective study of nine cases of PPPSC who were treated between January 2002 and April 2007 in METAXA Memorial Cancer Hospital, Piraeus, Greece. Medical files and histopathological diagnosis of each patient were retrospectively studied. RESULTS: The median age of the patients was 63 years ranging from 44 up to 74 years. Clinically PPPSC presented with general abdominal discomfort in all of the patients. Three out of nine patients presented with constipation, 5/9 with distention, and 7/9 with ascites. All of the patients referred loss of appetite with weight gaining due to ascites. All the patients had pathological values of CA125 (over 35 U/ml) ranging from 125 up to 1,255 U/ml with median value 565 U/ml. Optimal debulking was possible in 3/9 of patients who were consequently treated with standard taxol-platin chemotherapy. Complete response was achieved in one woman. The median disease-free survival was 7 months and the median overall survival rate was 2.5 years. CONCLUSION: PPPSC mimics ovarian papillary serous carcinoma regarding the clinical and laboratory characteristics but it has worse prognosis.

The histological outcome of glandular dyskaryosis--AGUS--reported in Papanicolaou smears.

PURPOSE: The objective of this study was to investigate the prognostic significance of glandular dyskaryosis/AGUS, reported in Papanicolaou (Pap) smears. MATERIALS AND METHODS: During a 4-year period 26,408 smears were assessed at the Department of Cytology of our hospital. Thirty (0.11%) smears were reported as having glandular dyskaryosis. The studied material was taken by colposcopy, fractional curettage and/or cone biopsy. RESULTS: The final diagnosis included 2 cases of invasive cervical carcinoma (1 squamous cell and 1 adenocarcinoma), 1 case with ovarian cancer, 8 cases with high grade squamous intraepithelial lesion (HGSIL) and 10 cases with other nonmalignant pathology (polyps, hyperplasia) of endometrial origin. These findings reflect a 36.7% positive predictive value for significant squamous and glandular pathology. CONCLUSION: Patients with glandular dyskaryosis require further evaluation because it may hide serious pathology from all internal genital organs. Colposcopy in combination with fractional curettage and/or cone biopsy are proposed as the appropriate diagnostic tools in women with such cytological abnormality.

Laparoscopic pelvic exenteration: a new option in the surgical treatment of locally advanced and recurrent cervical carcinoma.

Pelvic exenteration is an option in the treatment of persistent or recurrent cervical carcinomas confined to the central pelvis. The improvement of laparoscopic techniques and equipment in combination with broader experience of surgeons in laparoscopy made laparoscopic pelvic exenteration possible. This article reviews present experience with pelvic exenteration and analyses the advantages and disadvantages of the method compared to classical method (Tab. 2, Ref. 10).

Splenosis of the peritoneal cavity resembling an adnexal tumor: case report.

INTRODUCTION: Splenosis is the autoimplantation of ectopic spleen tissue in various anatomic cavities of the body resulting after trauma or rupture of the splenic parenchyma. The major localization sites of this phenomenon are mainly intraperitoneal, the gastrenteric tract, genitalia, intrahepatically and the kidneys. Extraperitoneal locations occur less frequently and include the thorax and brain. Also locallization in the subcutaneous fat has been described. CASE REPORT: We present the case of a 32-year-old woman with symptomatic peritoneal cavity splenosis occurring ten years after traumatic splenectomy. The patient was admitted to our department with the clinical presentation of an adnexal tumor. US and CT confirmed an adnexal mass. Exploratory laparotomy was performed and multiple focal lesions were noticed on the uterus, ovaries and intestinal tract. Biopsies were taken and sent for histological analysis. The pathology specimen revealed ectopic splenic tissue. After surgical intervention the patient remained asymptomatic. CONCLUSION: Splenosis is a rare phenomenon which clinicians should be aware of in order to spare patients from pointless surgical interventions. Patients with abdominal masses and post-traumatic splenectomy should be checked for splenosis.

Polymyositis in a patient with recurring ovarian cancer and history of unrelated breast cancer.

BACKGROUND: Polymyositis (PM) is an idiopathic inflammatory myopathy. Occasionally, it may present as a paraneoplastic syndrome and it is strongly associated with ovarian and weakly with breast cancer. We present here a case of a 60-year-old patient with sequential breast and ovarian (second primary) carcinomas followed by PM as a paraneoplastic disorder. CASE REPORT: The patient had been diagnosed with stage I breast carcinoma 3 years ago and had been treated with conservative surgery followed by radiotherapy and six cycles of chemotherapy (CMF). One and a half year later an ovarian carcinoma was diagnosed for which the patient underwent abdominal hysterectomy oophorectomy and omentectomy. The pathological report characterized it as second primary. Adjuvant chemotherapy with carboplatin and taxol was administered. Fourteen months after the initial laparotomy, the patient was re-operated due to ovarian carcinoma recurrence which was involving all lesser pelvis organs. After a successful radical removal of the recurrence the patient developed a fully expressed PM. This case serves to remind that this disease can occur as a paraneoplastic disorder.

Vaginal carcinoma in a completely prolapsed uterus. A case report.

BACKGROUND: The development of genuine vaginal carcinoma onto a completely prolapsed uterus is a very rare condition to deal with. CASE: We report here the clinical characteristics of a patient with vaginal carcinoma associated with a third-degree prolapsed uterus. The 80-year-old patient was admitted with a completely prolapsed uterus. The cervix was clinically normal but on the nearby prolapsed vaginal wall a large exophytical hard lesion had been developed. Biopsy of the lesion revealed squamous carcinoma. TREATMENT: The treatment performed was radical vaginal hysterectomy and excision of the upper two-thirds of the vagina without pelvic lymphadenectomy, followed by external beam irradiation. The patient is alive, with no signs of the disease 3.5 years after surgery. CONCLUSION: Surgical and radiotherapeutic treatments can be effectively combined in patients with vaginal carcinoma and complete genital prolapse, in order to improve survival benefits and reduce morbidity.

Giant solid abdominal mass with cystic lesions: a case report and diaphorodiagnostic approach.

A peri-menopausal woman presented with abdominal distention, pelvic discomfort and problems of constipation for the last 4 months. All clinical and radiological examinations were in favor of a giant solid mass with cystic lesions arised from the left ovary. These findings raised suspicion of a primary malignant ovarian tumor or a preudomyxoma peritonei. Surgery revealed a giant mass arised from the uterine fundus. An abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy were preformed. The histological examination verified a degenerated myoma with cystic lesions with no evidence of malignancy. The patient made an uneventful recovery. A gynecologist should always be prepared to perform a different surgery than planned according to operational findings (Fig. 2, Ref. 11).

Preoperative imaging of primary intra-abdominal gynaecological malignancies. Diagnostic accuracy of CT-scan and MRI. A Greek cohort study.

OBJECTIVES: To determine the radiological modalities that provide at the initial workout the most accurate information regarding the operability and the type of operation for patients with primary cervical, endometrial, and ovarian carcinomas. PATIENTS AND METHODS: The medical records of 611 patients with gynaecological cancer were reviewed. The preoperative radiological findings were compared with the intraoperative and pathological ones. The diagnostic accuracy of CT and MRI at various sites was evaluated for all three kinds of carcinoma in combination. RESULTS: MRI was more accurate than CT in determining cervical enlargement (82% vs 73%), parametrial invasion (91% vs 74%) and the only examination that could evaluate cervical tumour size as well as cervical stromal and myometrial infiltration. Regarding lymph node involvement their results were similar (86% vs 88%). Both methods were comparably accurate in evaluating ovarian tumours (82% vs 84%), ascites (82% vs 81%), omental (73% vs 77%) and mesenterial infiltration (88% vs 93%). They also proved to be highly accurate (100% vs 98%) in the evaluation of solid abdominal organs. CONCLUSIONS: Non-enchanced MRI should only be used for the preoperative evaluation of a patient with cervical carcinoma, while CT with intravenous and per os contrast media for one with ovarian cancer. Regarding patients with endometrial cancer, no high-resolution method is required for endometrioid grade I tumours, while contrast-enchanced MRI should be employed for all other cases.

Squamous vulvar cancer: a clinically based individualization of treatment.

OBJECTIVE: The aim of the study was to evaluate treatment results in 211 patients with previously untreated squamous cell vulvar cancer who were primary managed by surgery at the Gynecologic Oncology Unit of Alexandra Hospital, in terms of en bloc radical vulvectomy (N = 105), modified radical vulvectomy with three different incisions technique (N = 60), and radical hemivulvectomy (N = 46) with inguinofemoral lymphadenectomy. METHODS: The surgical stage of disease, nodal status, lesion location and focality, marginal status, tumor size, physical and performance status, surgical modality used, and finally complications and recurrence rates were the analyzed factors for both survival and disease remission. RESULTS: The overall 5-year survival was 70.1%. The 5-year survival for node-positive patients was 53.8% versus 79.7% for node-negative patients. Unifocal lesions had a 5-year survival of 76% compared with 50% of multifocal lesions. Posterolateral lesions had a better 5-year survival than that of anterior central lesions (79.5% vs 54. 4%). The marginal status of the surgical specimen was a significant predictor of both survival and recurrence. There was a significant difference in complications related to the en bloc radical vulvectomy in terms of wound breakdown, infection, and wound cellulitis. CONCLUSIONS: Modified radical procedures are equally effective with the en bloc radical vulvectomy for the management of early (stage I/II) vulvar cancer. In advanced disease concervative surgery in an individualized approach could also effectively be applied.

A phase II trial of methotrexate, vinblastine, doxorubicin, and cisplatin in the treatment of metastatic carcinoma of the uterine cervix.

BACKGROUND: Patients with metastatic carcinoma of the uterine cervix have limited survival. Thus, new chemotherapeutic agents and combinations are needed to improve patient outcome. METHODS: Twenty-seven patients with Stage IV primary or recurrent carcinoma of the uterine cervix were assigned to chemotherapy treatment at 4-week intervals with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC). The treatment was comprised of methotrexate, 30 mg/m2 administered intravenously (i.v.) on Days 1, 15, and 22; vinblastine, 3 mg/m2 i.v. on Days 2, 15, and 22; doxorubicin, 30 mg/m2 i.v. on Day 2; and cisplatin, 70 mg/m2 i.v. on Day 2. Granulocyte-colony stimulating factor (G-CSF) was given subcutaneously on Days 6-10 at a dose of 5 micrograms/kg. RESULTS: After a median of 4 cycles (a maximum of 6 in responders), the authors observed objective responses in 14 patients (52%), including 3 complete responses (11%) and 11 partial responses (41%). Median overall survival was 11 months (range, 4-15+ months), and median progression free survival of the responders was 8 months (range, 6-15+ months). Toxicity was acceptable and included neutropenia, alopecia, vomiting, and stomatitis. CONCLUSIONS: MVAC is an active regimen in the treatment of patients with advanced or recurrent carcinoma of the uterine cervix. It produced responses in one-half of the patients in this study, and it can be administered on an outpatient basis. The addition of G-CSF appears to reduce hematologic toxicity.

Ifosfamide and paclitaxel salvage chemotherapy for advanced epithelial ovarian cancer.

OBJECTIVE: To evaluate the efficacy and toxicity of the combination of ifosfamide (1.5 g/m2 i.v. on days 1, 2, 3) and paclitaxel (135 mg/m2 i.v. over 3 hours on day 3) with G-CSF (5 micrograms/kg/d subcutaneously, days 7-11) administered every 3 weeks on an outpatient basis in patients with advanced epithelial ovarian cancer previously treated with platinum-based chemotherapy. PATIENTS AND METHODS: Thirty-five consecutive patients were treated, 12 of whom had previously received two regimens. Twelve of the 35 were defined as platinum-resistant and 23 as potentially platinum-sensitive. RESULTS: Fifteen patients (43%; 95% CI: 26%-61%) achieved objective responses, five of them complete and ten partial. Objective responses occurred in 17% of the platinum-resistant patients and in 57% of those with potentially platinum-sensitive disease. The median duration of response was seven months and the median overall survival 11 months. The treatment was well tolerated and only 15% of the patients developed grade 3 or 4 neutropenia. With the exception of alopecia there were no other grade 3 or 4 toxicities. CONCLUSIONS: The combination of ifosfamide and paclitaxel was well tolerated and showed activity in patients with ovarian cancer who had previously undergone platinum-based chemotherapy.

Retroperitoneal endometriosis causing cyclical ureteral obstruction.

We report a case of retroperitoneal endometriosis involving the periureteral tissues of the left ureter. The patient suffered from cyclical symptoms of left ureteral obstruction during menstruation. Endometriosis of the ureter is not common and in this case the preoperative diagnosis presented difficulties due to the absence of any pathological findings during the clinicolaboratory evaluation of the patient before or after menstruation. The patient was managed with surgical resection of the affected ureteral segment and subsequent end-to-end anastomosis of the left ureter. A brief review of the subject is also presented.

Comparative study of RIS with the 131I-OC 125 F(ab')2 Mab and CT scan prior to second look operation for ovarian cancer.

A tumour-associated radiolabelled monoclonal antibody (Mab) 131I-OC 125 F(ab')2 was used to investigate 27 patients 2 weeks after their last chemotherapy regimen and prior to second-look surgery for ovarian cancer. We did compare the radioimmunoscintigraphy (RIS) findings with the CT scan results and the second-look operation data. In 23 out of 27 cases the RIS results correlated with the operation findings, while there were four false-negative results. Computed tomography (CT) scans correlated in 17 out of 23 cases with the operative findings, while there were six false-negative results. We concluded that RIS is more specific in detecting the tumour site within the pelvis, while CT scan is superior in detecting liver metastases.