Assisted reproduction in patients with early-stage ovarian malignancies

OBJECTIVE

To determine the outcome of women with early-stage ovarian malignancies who subsequently underwent assisted reproductive technologies (ART).

DESIGN

Retrospective study.

SETTING

Academic assisted reproductive technology program.

PATIENT(S)

Four infertile women who were previously diagnosed with early-stage ovarian malignancies.

INTERVENTION(S)

Controlled ovulation hyperstimulation, IVF, and/or gamete intrafallopian transfer treatments using clomiphene citrate and/or gonadotropins.

MAIN OUTCOME MEASURE(S)

Development of tumor recurrence and disease-free interval.

RESULT(S)

All four women remain free of disease for up to 15 years after treatment. Three of the four women achieved pregnancy.

CONCLUSION(S)

In patients with early-stage ovarian malignancies, conservative therapy followed by ovarian stimulation for assisted reproduction is an acceptable strategy.

Pregnancy outcomes in patients after radical trachelectomy

OBJECTIVES

This study was undertaken to review and analyze the fertility and pregnancy outcomes in patients who have undergone radical trachelectomy as the method of management of invasive carcinoma of the cervix.

STUDY DESIGN

All preoperative, operative, and follow-up data were collected prospectively. Perinatal information was completed by chart reviews and patient questionnaires.

RESULTS

Of 80 patients having undergone the above procedure, 39 have attempted to conceive for a median of 11 months (range 1-85). There have been a total of 22 pregnancies in 18 patients (4 patients pregnant twice). Of the 22 pregnancies, 18 were viable, with 12 progressing to term and delivering by caesarean section. Preterm premature rupture of membranes was the primary cause of preterm delivery.

CONCLUSION

This series confirms that pregnancy is a safe and realistic outcome for women undergoing radical trachelectomy for invasive carcinoma of the cervix. Given the apparently high incidence of preterm premature rupture of membranes, these pregnancies should be managed as high risk.

[Pregnancy and delivery in a woman after treatment for ovarian cancer]

The course of pregnancy and delivery in woman after surgical and multiagent chemotherapy of ovarian cancer was observed. A pregnancy complicated EPH-gestosis. The patient delivered infant with IUGR symptom's by cesarean section at 37 week of pregnancy. There were no clinical or macroscopic symptoms of the disease.

Benign struma ovarii complicating pregnancy: a case report and review of the literature

INTRODUCTION

Struma ovarii is a type of mature ovarian teratoma consisting mainly of thyroid tissue. The rarity of this tumor in pregnancy and the risk of malignancy make difficult the diagnosis and the management.

CASE REPORT

We report a case of benign struma ovarii initially detected as an ovarian mass at the first trimester of pregnancy.

Paclitaxel and carboplatin chemotherapy administered during pregnancy for advanced epithelial ovarian cancer

BACKGROUND

Ovarian cancer diagnosed during pregnancy is uncommon. Most chemotherapy use reported has been in combination with cisplatinum. Paclitaxel in combination with carboplatin during pregnancy has not yet been reported.

CASE

A right adnexal mass was diagnosed during pregnancy at 5 weeks' gestational age in a 30-year-old woman. A laparotomy was performed 2 1/2 weeks later because of the worsening nature of her symptoms and the possibility of ovarian torsion. At surgery, the patient was diagnosed with stage IIIC ovarian papillary serous cystadenocarcinoma. She was treated with six cycles of paclitaxel and carboplatin beginning at 16-17 weeks' gestation. At 35.5 weeks' gestation, a cesarean hysterectomy, left salpingo-oophorectomy, and pelvic and paraaortic nodal sampling with multiple peritoneal biopsies was performed without incident. However, the patient had refractory disease present in the remaining ovary. She was treated with further chemotherapy and is currently doing well. The patient experienced no adverse reactions during her treatment, and the infant has normal growth and development at 15 months of age.

CONCLUSION

Paclitaxel used in combination with carboplatin for the treatment of ovarian cancer during pregnancy caused no adverse effects in the infant.

Büschke–Lowenstein tumour in pregnancy

During pregnancy a localised human papillomavirus (HPV) lesion may, in rare cases, develop into a Büschke-Lowenstein tumour. The choice of treatment is crucial as standard systemic treatment is teratogenic. We performed laser CO2 microsurgery because it has a low incidence of complications.

Ultrasound-guided interstitial laser therapy for the treatment of placental chorioangioma

BACKGROUND

Placental chorioangioma is a relatively rare malformation with potential to cause fetal hydrops and even death. We describe ultrasound-guided interstitial laser as a modality for treating chorioangiomas of the placenta.

CASE

The patient presented at midgestation with placental chorioangioma resulting in fetal cardiomegaly. Interstitial laser was performed under local anesthesia on two occasions and resulted in arrest of flow through the tumor feeder vessel.

CONCLUSION

Interstitial laser therapy in a patient with placental chorioangioma resulted in a successful outcome.

Mucinous appendicular cystadenocarcinoma during pregnancy. A case report

BACKGROUND

Primary appendicular adenocarcinoma is a rare type of appendicular carcinoma. We report mucinous appendicular adenocarcinoma during pregnancy. To our knowledge, this is the third reported case.

CASE

A 35-year-old woman at 21 weeks of gestation presented with acute abdominal symptoms for the previous 10 days and underwent appendectomy. Histopathologically, examination of the appendectomy material was reported as "mucinous appendicular cystadenocarcinoma." The pregnancy was terminated by misoprostol induction. A right hemicolectomy and staging procedure were performed on the third postpartum day with relaparotomy.

CONCLUSION

Although it rarely coexists with pregnancy, primary appendicular adenocarcinoma should be considered in pregnant women with atypical acute abdominal symptoms of long duration. Primary adenocarcinoma of the appendix should be treated with right hemicolectomy even if it is a secondary procedure. Termination of pregnancy is not essential to the surgical procedure, and the decision on the outcome of the pregnancy should be made with the patient.

Prise en charge d’une néoplasie intra-épithéliale du col de l’utérus en cours de grossesse

Approximately 30% of women diagnosed with cervical cancer are in their childbearing years. Prenatal care provides an excellent opportunity for cervical cancer screening. The incidence of abnormal Pap smear has been reported in 5-8% of pregnant women. But we must know that Pap smears have cytologic modifications because of pregnancy. All abnormal smears have to be referred to colposcopic examination. The squamocolumnar junction is visualized in almost 100% of cases. The sensitivity of colposcopy is nearly 87% with complete concordance in 72.6%. Colposcopically directed biopsies have a good correlation with the final diagnosis with very minimal risks for both mother and fetus. The high rate of complications (hemorrhage, abortion, premature labor) and residual lesions in half of cases do not encourage conization during pregnancy. The final treatment is carried out after delivery. The only absolute indication for conization in pregnancy is to rule out microinvasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing of delivery but also when there is a no satisfactory colposcopy and a high-grade Pap smear. In these cases conization is performed for diagnostic and not therapeutic purpose. We must be aware of the high rate of loss of follow-up (6-33%).

[Colon cancer in pregnancy]

Colon cancers arise only rarely in the course of a pregnancy. Yet colon obstruction, perforation and metastatic spread seem to occur more frequently in this setting than with the average colon cancer. Perhaps this is due to the immunotolerance which accompanies pregnancy. No case of epidermoid (squamous cell) cancer of the colon has been previously described in a pregnant woman. This conjunction has a catastrophic prognosis: the diagnosis of colon tumor is delayed since symptoms are masked by the pregnancy, and epidermoid colon cancer is a particularly aggressive lesion. A major sub-diaphragmatic surgical procedure can be performed with reasonable safety to mother and fetus. Radiotherapy is contraindicated. Neo-adjuvant chemotherapy can be administered although the risks to the fetus are not well known. During the first trimester, a therapeutic abortion can be proposed to optimise the treatment of the mother. During the second and third trimesters, treatment of the mother exposes the fetus to the risk of malformations or premature delivery; delay in maternal treatment in hopes of prolonging the pregnancy in order to obtain a viable neonate diminish the chances of maternal survival.

Rapidly growing sublingual dermoid cyst throughout pregnancy

Dermoid cysts (DCs) are subcutaneously located cystic masses that contain epithelium and adnexal structures. They are most commonly located in the ovaries and sacral region. Seven percent of DCs are found in the head and neck. Sublingual DCs may develop above the mylohyoid, presenting in the floor of the mouth or below it, causing a submental or submaxillary mass. We presented a case with a sublingual giant DC enlarged rapidly during pregnancy manifesting deglutition and mild respiratory problems. The growth of a DC of the neck may be accelerated in pregnancy period and may ensue severe symptoms challenging both mother and fetus. We proposed the removal of sublingual DCs before attempting to conceive to eliminate the risk of rapid growth of DC that results in respiratory and deglutition problems.

[Thyroid carcinoma and pregnancy]

The authors refer particular aetiological features, prognostic e different types of thyroid carcinoma treatment on pregnant women. There are also other kind of tumours occurring during this time, although not so frequent. There are some protocols in discussion to treat these kind of thyroid carcinoma, considering that the problem must be specified according to the type of tumour, stadium, pregnancy time and the patient psychological state.

[The course of a multipara's pregnancy, labour and puerperium complicated by spleen tumor]]

DESIGN

The multipara with spleen's tumor was diagnosed and observed during pregnancy, labour and puerperium. The spleen's tumors are very rare and they should be examined individually. Termination of the pregnancy by cesarean section was performed because of the big risk for the mother and child (tumor's crack, haemorrhage, infection). After 3 months post partum the spleen with tumor was operated (splenectomy). It was cystic spuria.

RESULTS

The cystic spleen was diagnosed by accidental abdominal USG and this test prevented threatening complications.

CONCLUSIONS

The abdominal USG should be used in pregnancy.

Successful myomectomy during pregnancy

BACKGROUND

Although leiomyomas usually remain asymptomatic during pregnancy, they may complicate its course. In this study, pregnancy outcome observed when myomectomy was performed during pregnancy in carefully selected patients is presented.

METHODS

A prospective cohort study of 13 women who underwent myomectomy during pregnancy between January 1994 and December 2001. Surgical management of leiomyoma was required on the basis of characteristics of the myoma and symptoms.

RESULTS

Among a total of 15,579 women registered at the authors' prenatal clinic, 622 consecutive pregnant women had sonographically identified myoma; hence, the incidence was 3.9% (95% CI 3.6-4.3%). The vast majority of these women was asymptomatic during pregnancy or managed conservatively (97.4%; 95% CI 96-98%). Among 622 pregnant patients with leiomyoma, 13 presented with complications during pregnancy that required surgical intervention (2.1%; 95% CI 0.9-3.2%), due to increase in lesion size causing discomfort and/or severe abdominal pain not responding to conservative management with analgesic and non-steroidal anti-inflammatory drug medication. In 92% of these cases, successful myomectomy was performed and the pregnancy progressed to term without further complications.

CONCLUSIONS

These data provide reassurance for pregnant women with uterine myoma. Surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients.

Uterusmyome?Behandlungsoptionen aus der Sicht des Gyn�kologen

Uterine fibroids are the most common benign tumour affecting the female reproductive tract, 20% of all women older than 35 years are afflicted. Patients with fibroids tend to be asymptomatic, but fibroids may lead to meno-, metrorrhagia, hyper- and dysmenorrhoea and urination and defecation problems. If the fibroids do not cause any clinical symptoms and if there is no suspicion of a malignant tumor, there is no need for therapeutic intervention. Otherwise, besides the medical management with gestagenes and GnRH (gonadotropin-releasing hormone) analog, surgery represents the classical treatment. Hysterectomy is the common approach for women with completed family planning. For women who wish to conserve their fertility enucleation of the fibroids can be considered. These surgical procedures can be performed endoscopically or abdominally. Uterine artery embolisation, a radiological intervention, is less invasive and represents an interesting therapeutic alternative.

Laparoscopic adrenalectomy--indications and technique

Laparoscopic adrenalectomy has become the procedure of choice for the surgical management of most adrenal tumors, including functional and non-functional lesions. The role of laparoscopic adrenalectomy in the management of malignant adrenal tumors is controversial and most adrenocortical cancers are generally treated by open adrenalectomy. Laparoscopic adrenalectomy can be performed by both the anterior or lateral trans-abdominal approach and by the lateral or posterior retro-peritoneal approach, with each method being suitable for specific indications. Although there are no randomized trials comparing laparoscopic with open adrenalectomy, the laparoscopic approach is associated with shorter hospital stay, reduced pain and improved cosmesis. This review discusses the indications and contraindications, technique and outcomes for laparoscopic adrenalectomy.

[Primary hyperthyroidism after excision of a Struma ovarii]

Struma ovarii is a teratoma composed of thyroid tissue and can be a rare cause of hyperthyroidism. We report a 35 years old woman with a left ovarian mass whose pathology revealed a Struma ovarii. This tumor was partially excised initially to avoid fertility problems and after a successful gestation, the tumor was completely removed during a cesarean section. Sixty days after delivery a hypothyroidism was diagnosed. Levothyroxine was started and euthyroidism was achieved.

Leiomyoma of the urinary bladder during pregnancy

We present a rare case of leiomyoma of the urinary bladder that was diagnosed during pregnancy. To our knowledge, this is the fourth case of its kind to be reported in the literature. Ultrasonography, magnetic resonance imaging and biopsy were useful for making an accurate diagnosis in this case. The diagnosis was confirmed by suprapubic transcutaneous needle biopsy. The tumor was resected approximately 3 years after diagnosis, during which period the patient delivered a normal baby by caesarian section.

[Laparoscopic management during pregnancy--own material (1996-2002)]

OBJECTIVE

Utility of laparoscopic procedures in pregnant women. Is laparoscopy safe for the foetus?

MATERIAL AND METHODS

Between 1996 an 2002 14 pregnant patients were admitted and laparoscopy was performed.

RESULTS

In 10 cases laparoscopic cyst enucleation (6 simplex, 1 endometrial, 3 dermoidal), in 1 case myomectomy and in 2 adnexectomy was performed. There were no complications during surgery. In one case miscarriage occurred 3 weeks after laparoscopic surgery and 9 healthy babies were delivered.

DISCUSSION

There is no doubt that laparoscopy is well accepted in gynecological surgery and is going to be more and more accepted in obstetrics. Due to several differences between non-pregnant and pregnant women laparoscopic procedures in pregnancy require special attention. All papers show good foetal outcome even with preterm labour. In our material all babies were born healthy.

CONCLUSIONS

Laparoscopic procedures during pregnancy are feasible and safe. Nevertheless they have to be performed by experienced gynecological-surgical teams.

[Burkitt lymphoma involving the ovaries]

Burkitt lymphoma is a very rare type of lymphoma with a predilection for the ovary. We report a case of 18-years old woman with dramatic course of the Burkitt lymphoma involving ovaries. Immunohistochemistry techniques allowed for the diagnosis and the successful chemotherapy. The case demonstrates the importance of an appropriate pathology evaluation and interdisciplinary collaboration.

[Cutaneous melanoma during pregnancy at the Cancer Center-Institute in Warsaw]

Malignant melanoma is a neoplasm which frequency has been increasing rapidly in Poland. The paper describes five cases of patients with cutaneous melanoma coexisting with pregnancy, who have been recently treated in the Department of Soft Tissue/Bone Tumors of M. Sklodowska-Curie Memorial Cancer--Institute of Oncology, Warsaw. All patients presented clinically advanced primary lesions with poor prognosis. In paper recommendations for treatment of women with suspicious cutaneous lesions before or during pregnancy and patients with melanoma planning a pregnancy are presented. The suspicion of melanoma is indication for immediate excisional biopsy by local anesthesia. Further treatment should be performed in tertiary oncological centres. There is no evident clinical data that pregnancy has a significant impact on progression of melanoma. The most important factor influencing prognosis of melanoma is the stage of the disease at the diagnosis. There are no grounds for abortion in pregnant women with melanoma in I/II/III stages.