Transrectal ultrasound and magnetic resonance imaging in the evaluation of tumor size following neoadjuvant chemotherapy for locally advanced cervical cancer.

OBJECTIVES: To assess the accuracy of magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) in the evaluation of tumor size and in the detection of residual tumor following neoadjuvant chemotherapy (NACT) in patients with cervical cancer. METHODS: This was a prospective study involving 42 women with locally advanced histologically confirmed cervical cancer referred for NACT. Clinical examination, TRUS and MRI were performed before and after NACT. The tumor volume was calculated using three standardized diameters (anteroposterior, laterolateral and craniocaudal) that were measured using both TRUS and MRI. Thereafter patients underwent surgical treatment and the same tumor measurements were taken by a pathologist using a fixed surgical specimen. Tumor volumes were calculated from tumor dimensions using the ellipsoid formula, and data obtained from both imaging methods were compared with pathological results as the gold standard. RESULTS: Twelve cases were excluded from the study owing to disease progression (these patients were referred for primary radiotherapy) or inability to perform MRI, leaving data from 30 patients for the final analysis. On average, tumor volume decreased after NACT by 84.6 and 87.1% as measured by MRI and TRUS, respectively. The agreement between measurements obtained by MRI and histology did not reach significance (intraclass correlation coefficient, 0.344 (95% CI, -0.013 to 0.610), P = 0.059), while agreement between TRUS and histology was statistically significant (intraclass correlation coefficient, 0.795 (95% CI, 0.569-0.902), P < 0.001). The accuracy of residual tumor detection (for non-microscopic tumors > 5 mm3 in volume) reached 77% for both MRI and TRUS. The sensitivity of TRUS was, however, lower than that of MRI (83 vs. 96%). The positive predictive values were similar for the two methods. CONCLUSIONS: TRUS should be considered as an accurate diagnostic method in the evaluation of tumor volume after NACT in patients with cervical cancer and may constitute a reliable alternative imaging method to MRI.

[Detection of HPV DNA in lymph nodes in early stages cervical cancers]. / Stanovení DNA HPV v lymfatických uzlinách u casných stadií karcinomu delozního hrdla.

OBJECTIVE: Review recent knowledge concerning significance of detection of DNA HPV in regional lymph nodes in cervical cancer patients. TYPE OF THE STUDY: Literature review. SETTING: Department of Obstetrics and Gyneacology, 1st Faculty of Medicine, Charles University and General Teaching Hospital, Prague. RESULTS: Metastatic involvement of pelvic lymph nodes is the most important prognostic parameter in early stages cervical cancer. Still, almost 20% of patients with negative pelvic nodes experience recurrence. Detection of HPV DNA in lymph nodes might be a marker of occult metastatic involvement. However, published data are limited, mostly due to inconsistent methodology. Only 3 prospective studies evaluating HPV from fresh or frozen tissue were published till now, all other retrospective studies extracted HPV DNA from paraffin embedded samples. A few papers showed correlation between HPV DNA and metastatic involvement of pelvic lymph nodes. DNA HPV identification in histopatology-negative nodes was considered as a risk factor for recurrence. Presence of DNA HPV 18 in histopathology-negative pelvic nodes was described as a poor prognostic factor; however prognostic significance of individual genotype is still unclear. CONCLUSION: Detection of high risk HPV DNA in regional lymph nodes is a good candidate for prognostic parameter in early stages cervical cancers. The group of women with both absence of metastatic involvement and negative HPV DNA evaluation of regional lymph node should represent a cohort of patients with particularly good prognosis.

[Radical parametrectomy in women with invasive cervix cancer after previous simple hysterectomy]. / Radikální parametrektomie u zen s invazivním karcinomem delozního hrdla po piredchozí prosté hysterektomii.

OBJECTIVE: Evaluate technique, indications and limits of surgical procedure in the treatment of cervical cancer diagnosed from uterus specimen from simple hysterectomy. DESIGN: Retrospective observational study, review of literature. SETTINGS: Department of Obstetrics and Gynecology, 1st Medical Faculty and General Faculty Hospital, Charles University, Prague, Czech Republic. METHODS: Women following radical parametrectomy with upper vaginectomy and pelvic lymphadenectomy were enrolled to the study. In all patients unexpected invasive cervical cancer was found from the uterus specimen after simple hysterectomy. RESULTS: Together 10 patients were enrolled to the study. CIN was the indication for primary hysterectomy in all but two patients. There were two operative complications, cystostomy in both cases, treated properly during surgery. In the specimen from radical procedure residual tumor in parametria was found in 2 cases, and metastasis to pelvic nodes in 4 cases. There was no postoperative complication. Adjuvant radiotherapy was recommended in 4 patients due to positive lymph nodes, in one case due to residual tumor in parametria, and in one case for both reasons. CONCLUSIONS: Radical parametrectomy with upper vaginectomy and pelvic lymphadenectomy should be considered as an alternative solution in patients following simple hysterectomy with unexpected finding of invasive cervical cancer. Morbidity of the procedure is higher in comparison to standard radical hysterectomy, however majority of complications are easy to repair. The most significant criteria for patient's selection for surgical approach is a depth of invasion to cervical stroma. In our group radical procedure obviated the need for radiotherapy in half of the patients.

[Exenteration procedures in the pelvis]. / Exenteracní výkony v páinvi.

Exenteration pelvic procedures are surgical options for treatment of locally advanced pelvic tumors. Due to the procedure's success rates, it has become a standard therapeutic procedure, when indicated. From the medical point of view, the following factors characterize the level of seriousness of these procedures: the fact that the procedure is extensive, its complicated reconstruction phase and high postoperative morbidity rates. From the patient's point of view, it is characterized by a principal change in the quality of life. In this case review the authors present their experience with a multidisciplinary approach to these procedures.

[Embolization of uterine arteries during myoma treatment from the patient's point of view]. / Embolizace delozních tepen pri lécbe myomu z pohledu pacientek.

OBJECTIVES: To acquire information about the patient's follow-up evaluation of treating fibroids by uterine artery embolization (UAE). DESIGN: A retrospective multicenter clinical trial. SETTING: Department of Obstetrics and Gynaecology, 1st Faculty of Medicine and the General Faculty Hospital, Charles University, Prague. METHODS: 45 women who underwent the UAE due to uterine fibroids from 1999 to 2003 were asked to complete a questionnaire. The questionnaire included 26 questions asking how the women had been informed and what they had expected. Further questions were focused on the course of embolization itself, early post-procedural difficulties (post-embolization syndrome) and patient's overall evaluation of treatment in a longer term. Those women who had completed the questionnaire and had been ready to co-operate were thereafter examined and included in the follow-up monitoring and, if necessary, further treatment was recommended. RESULTS: Thirty one out of 45 patients from 26 to 48 years of age, who had been addressed (68.9%) answered the questionnaire. UAE was indicated 12 times (38.7%) on account of symptoms, 10 times (32.3%) because of sterility, 5 times (16.1%) as a preventive measure within the framework of family planning and 4 times (12.9%) for an asymptomatic but growing leiomyoma. Twenty seven (87.1%) women were also offered an alternative treatment, which they refused. As far as problems are concerned, 18 (58%) women described the course of treatment as corresponding with what they had expected, 5 times it was less painful, and 8 times it was worse than expected. The long-term results were considered as positive by 87.1% of responders, only 12.9% considered the treatment as failure. 5 in 11 women planning pregnancy became pregnant, 3 of them gave birth in term and 2 miscarried in the 1st trimester. CONCLUSION: From the point of view of the patients, the evaluated method proves highly successful, it is well tolerated and it involves a low risk of complications. It is not possible, at this point, however, to give an unequivocal answer to the question whether the method should also be routinely offered to women who are planning pregnancy.

[Abdominal radical trachelectomy--technique and experience]. / Abdominailni radikailni trachelektomie--technika a zkusenosti.

OBJECTIVE: Discussion of current experiences with abdominal radical trachelectomy in the treatment of early stages of cervical cancer in fertile women. DESIGN: Case-reports. SETTING: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague. METHODS: Presentation of 4 cases of abdominal radical trachelectomy and pelvic lymphadenectomy. Discussion with published data. RESULTS: Three cases of open abdominal and one case of laparoscopic abdominal radical trachelectomies together with pelvic lymphadenectomies are presented. All procedures were indicated for cervical cancer stages IA2-IB1. Frozen section of pelvic nodes and a slice of upper margin of cervix revealed no metastasis or infiltration. In total 22-43 pelvic nodes were removed, being negative in all cases. Operative time ranged between 148 and 270 min. in laparotomy and 250 min. in laparoscopy. Blood loss reached 350-3500 ml. There were no intraoperative complications, postoperatively one case of bladder atony was treated by suprapubic drainage for 30 days, one case of ileus was managed pharmacologically. Vaginal suture healed properly in all cases. No complications occurred within limited follow-up of 1-5 months. CONCLUSION: Abdominal radical trachelectomy with pelvic lymphadenectomy is a rational alternative in the treatment of stages IA2-IIA cervical cancer in women of fertile age. Standard radicality in parametria resection and easy incorporation into armamentarium of oncogynecological centers are main advantages of such approach. Laparotomy can be avoided using laparoscopy.

[Initial experience in exenteration interventions in the pelvis]. / První zkusenosti s exenteracními výkony v pánvi.

OBJECTIVE: Discussion of experiences with pelvic exenterations. DESIGN: Case-report. SETTING: Department of Obstetrics and Gynecology, Department of Urology, Department of Surgery, Department of Pathology, Department of Clinical Oncology, General Teaching Hospital and Ist Medical Faculty of the Charles University, Prague, Czech Republic. METHODS: Presentation of 4 cases of pelvic exenterations. Discussion with published data. RESULTS: Altogether four cases of pelvic exenterations are presented, one case of supralevator total exenteration for recurrent cervical cancer, one case of infralevator total exenteration for recurrent vaginal cancer, one case of supralevator anterior exenteration in the treatment of locally advanced cancer of urinary bladder, and one case of supralevator posterior exenteration for recurrent vaginal cancer.

[The First Results of 360 degrees Fusion and Video-assisted Minimally Invasive Retroperitoneal Approach to the Lumbar Spine.]. / První výsledky se 360 degrees spondylodézou a video-asistovaným, minimálne invazivním retroperitoneálním prístupem k bederní páteri.

The authors present short-term results of a 360 degrees fusion together with the experience in their own modification of minimally invasive retroperitoneal approach to the lumbar spine. In the course of 1998 and 1999 they operated on the total number of 21 patients using this approach. The anterior approach was considered as part of the combined operation on the lumbar spine which was indicated for degenerative, traumatic, tumorous and iatrogenic instability of the lumbar spine. They evaluated blood loss, duration of the surgery, duration of image intensifier exposure, restoration of the peristalsis, satisfaction of the patient with the operation by means of Visual Analog Scale and in 12 patients who exceeded a twelvemonth of the follow-up also healing of the fusion on dynamic radiographs of the lumbar spine. The results are very optimistic. As compared to a classical approach they achieved low blood loss, short duration of the surgery, a quick restoration of peristalsis and a reduction of postoperative morbidity. An undoubted advantage of the presented technique is the economic thriftiness as concerns special endoscopic devices, retraction frames, microscope, special instruments or expansion devices. During the evaluation of the fusion no development of a nonunion or migration of grafts or cages was recorded. Also the satisfaction of patients after the operation was high and in the following period it even increased. Key words: lumbar spine fusion, retroperitoneal approach, minimally invasive surgery.

[Interleukin-6 and acute phase reactants in the diagnosis of ovarian carcinoma]. / Interleukin-6 a reaktanty akutní fáze v diagnostice ovariálního karcinomu.

In 115 women (healthy controls and patients with benign and malignant gynaecological tumors) interleukin-6 was determined in blood plasma with the aim to decide whether elevated IL-6 levels may be used as a marker of ovarian carcinoma. In spite of statistically significantly increased IL-6 levels the authors do not regard at present the IL-6 values as a useful marker of ovarian carcinoma for two reasons: first, until now it is not decided whether elevated IL-6 values originate only from the cells of epithelial ovarian carcinoma or if they are also produced by tumour-associated macrophages or both and second: in a large number of cases (both controls and patients with malignant tumors) no IL-6 levels in blood plasma could be detected. For these reasons it seems to be more convenient (even economically) to determine in suspected cases and after exclusion of any inflammatory process the levels of prealbumin and transferrin. Significantly decreased levels of both have a high value of primary sensitivity (66% and 87% resp.).