Is the extent of lymphadenectomy a prognostic factor in International Federation of Gynecology and Obstetrics stage II endometrioid endometrial cancer?

AIM

This study aimed to evaluate the prognostic significance of adequate lymph node dissection (LND) (≥10 pelvic lymph nodes (LNs) and ≥ 5 paraaortic LNs removed) in patients with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrioid endometrial cancer (EEC).

METHODS

A multicenter department database review was performed to identify patients who had been operated and diagnosed with stage II EEC at seven centers in Turkey retrospectively. Demographic, clinicopathological, and survival data were collected and analyzed.

RESULTS

We identified 284 women with stage II EEC. There were 170 (59.9%) patients in the adequate lymph node dissection (LND) group and 114 (40.1%) in the inadequate LND group. The 5-year overall survival (OS) rate of the inadequate LND group was significantly lower than that of the adequate LND group (84.1% vs. 89.1%, respectively; p = 0.028). In multivariate analysis, presence of lymphovascular space invasion (LVSI) (hazard ratio [HR]: 2.39, 95% confidence interval [CI]: 1.23-4.63; p = 0.009), age ≥ 60 (HR: 3.30, 95% CI: 1.65-6.57; p = 0.001], and absence of adjuvant therapy (HR: 2.74, 95% CI: 1.40-5.35; p = 0.003) remained as independent risk factors for decreased 5-year disease-free survival (DFS). Inadequate LND (HR: 2.34, 95% CI: 1.18-4.63; p < 0.001), age ≥ 60 (HR: 2.67, 95% CI: 1.25-5.72; p = 0.011), and absence of adjuvant therapy (HR: 4.95, 95% CI: 2.28-10.73; p < 0.001) were independent prognostic factors for decreased 5-year OS in multivariate analysis.

CONCLUSION

Adequate LND and adjuvant therapy were significant for the improvement of outcomes in FIGO stage II EEC patients. Furthermore, LVSI was associated with worse 5-year DFS rate in stage II EEC.

Seronegative systemic lupus erythematosus: etiology of nephrotic syndrome and acute renal failure in early postpartum period

Systemic lupus erythematosus (SLE) is an autoimmune syndrome that occurs most commonly in women during their reproductive years. Nephritis is known to be one of the most serious complications of SLE. Lupus nephropathy is frequently associated with ANA and anti-dsDNA antibodies. Rarely, serological markers may be initially absent, and in many cases, they become positive after sometime.

We present a 28-year old, otherwise healthy female who admitted to our clinic with edema, hypertension, proteinuria and acute renal failure following her fourth delivery. Serum immunological markers were negative and renal biopsy showed histopathological changes consistent with systemic lupus erythematosus as the etiology of nephrotic syndrome. A dramatic therapeutic response was achieved by pulse steroid and cyclophosphamide treatment following oral steroid therapy.

In women with new onset nephrotic syndrome or renal function deterioration in postpartum period, even if the patient is asymptomatic or seronegative, it is crucial to exclude SLE for a rapid diagnosis and prompt treatment in the case of lupus nephritis. Renal biopsy is of diagnostic importance in such cases in which there is no other clinical, biochemical and serological evidence of the disease.

Is colposcopic evaluation necessary in all women with postcoital bleeding?

OBJECTIVE

To evaluate what extent postcoital bleeding (PCB) is an indicator of cervical cancer (CIN2 (+)).

METHODS

This is a retrospective cohort study. Between 2007 and 2013, amongst all referred patients, a total of 1491 consecutive women who had both conventional cytology and cervical biopsy were enrolled in the study. Of those 237 women have PCB, according to biopsy results, subjects were divided into two groups: CIN1 (-) and CIN2 (+). Multiple logistic regressions was used to construct a model to predict the occurrence of CIN 2 (+) based on age, menopause, marriage status, smoking, PCB, HPV and cytology.

RESULTS

Among the all women with CIN 2 (+) colposcopy guided biopsy result, PCB was 13.1% (53/406). The relationship between biopsy results and age, parity, menopausal status, marital status, smoking, presence of PCB, HPV DNA, and cytology is statistically significant (p=0.012, p=0.001, p=0.023, 0.013, p>0.001, p=0.038, p<0.001, p<0.001, respectively). According to regression analysis only smoking, HPV (+) and abnormal cytology increase the probability of CIN2 (+); 1.687 times (p=0.018), 4.065 times (p<0.001), 5.787 times (p=0.001) respectively. Having PCB only does not indicate an increased risk of CIN2 (+).

CONCLUSION

Colposcopic examination and biopsy should be performed only in the situation where women have PCB and any of the following: smoking, positive HPV, or abnormal cytology.

Transobturator tape operation is more effective in premenopausal women than in postmenopausal women with stress incontinence

PURPOSE

Midurethral synthetic slings for female stress urinary incontinence are minimally invasive polypropylene mesh tapes that are inserted under the midurethra with trocars. In the past decade, this new technology has become the most commonly performed procedure for female stress urinary incontinence, replacing the traditional open procedures. However, its effectiveness in pre- and postmenopausal women has not previously been compared.

MATERIALS AND METHODS

We assessed the clinical outcome of the transobturator tape (TOT) procedure in premenopausal (n=45) and postmenopausal (n=49) women by means of self-report and the Urinary Distress Inventory 6 (UDI-6) questionnaire.

RESULTS

The mean age of the pre- and postmenopausal women was 44 and 60 years, respectively. Mean parity was 2.4 and 3, respectively. There were no significant differences with respect to mean operation time, duration of hospitalization, or intraoperative and postoperative complications. However, premenopausal women were more satisfied with the operation than were postmenopausal women (p=0.014). Also, UDI-6 scores were significantly better in premenopausal women (p=0.027).

CONCLUSIONS

The TOT operation appeared to be more effective in premenopausal women with stress urinary incontinence. However, further studies with larger sample sizes are needed to confirm our results.

Antioxidant prophylaxis for cellular injury in ovarian surface epithelium resulting from CO₂ pneumoperitoneum in a laparoscopic rat model

OBJECTIVE

Selective cytoprotective functions of vitamin E, N-acetyl-L: -cysteine, and amifostine have been used as a preventer of ischemia injury by expelling the free oxygen radicals leading to stabilization of the cellular membranes. The purpose of this experimental study was to investigate the oxidative stress related to cellular injury in ovarian surface epithelium and the effect of prophylaxis with an anti-oxidant using laparoscopic rat model.

DESIGN

Laparoscopic rat model.

MATERIALS AND METHODS

Randomly allocated 40 Wistar Albino female rats have been used for the pneumoperitoneum model which was constituted to fix the intraabdominal pressure on 5 mmHg for 60 min. The antioxidants, vitamin E and NAC were given to rats 3 days before the operation and were applied for 30 days; amifostine was applied 30 min before the operation until after for 7 days. After abdominal desufflation, over biopsies were made on the 13th min, 24th h, and 7th and 30th days. By using of transmission electron microscopy, the damage on cells and organels were assessed and graded.

RESULTS

In ovarian surface epithelium, the apical surface specializations were affected in all groups except Vit E group:The microvilli were irregular and coarse and had disappeared in some places. Some cells were separated from the epithelium. In addition, mitochondria degeneration was observed in all group except Vit E.

CONCLUSIONS

In the early period of laparoscopy, reversible cellular damage occurs and this damage can be prevented by vitamin E.

Bilateral breast metastasis of ovarian carcinoma

Primary breast carcinoma is the most common malignancy in women, however, metastatic breast carcinoma is rarely seen in clinical practice. It has been reported that lymphoma-leukemia, melanoma and sarcomas, the most common primary malignancies, can metastasize to the breast. On the other hand, ovarian carcinoma and other gynecologic cancers rarely develop into breast metastasis. However, the incidence of breast metastasis arising from ovarian carcinoma might be increasing as a result of prolongation in survival and improvement in treatment modalities. Bilateral breast metastasis originating from an ovarian carcinoma is an extremely rare clinico-pathological situation. In our literature review we found just nine cases of bilateral breast metastasis from primary ovarian carcinoma. In this study, the mean age was 46 years (range 16-68). Mean interval from initial diagnosis of ovarian carcinoma to bilateral breast metastases was 22 months (range 11-24) and mean survival was 12 (range 5-27) months after the diagnosis of breast metastasis. Serous papillary adenocarcinoma was the predominant histological subtype. Interestingly, five of the nine (56%) cases reported were from Turkey. This interesting observation can be explained by a genetic predisposition, but it requires further research. In conclusion, although it is a rare entity, breast metastasis should not be ruled out in patients with a history of ovarian carcinoma, if patients present with any symptoms of breast diseases.

Sublingual misoprostol after surgical management of early termination of pregnancy

OBJECTIVE

To assess the efficacy of sublingual misoprostol after surgical management of early termination of pregnancy (ETP) regarding duration and amount of bleeding, presence of retained products of conception (RPOC), and endometrial thickness.

DESIGN

Prospective, randomized clinical trial.

SETTING

University hospital.

PATIENT(S)

One hundred five patients admitted for possible management of early pregnancy failure and unwanted pregnancy.

INTERVENTION(S)

Manual vacuum aspiration (control and study groups) plus 400 microg sublingual misoprostol (study group) at pregnancy termination, and transvaginal ultrasonography (both groups) 10 days after the procedure.

MAIN OUTCOME MEASURE(S)

Duration and amount of bleeding and presence of RPOC and endometrial thickness 10 days after the procedure.

RESULT(S)

Bleeding lasted 3.2 and 5.1 days in the study and control groups. Severe vaginal bleeding occurred in two patients in the study group and in six patients in the control group. Mean endometrial thickness was 5.5 mm in the study group and 6.9 mm in the control group. These differences were statistically significant. No cases of RPOC occurred in the study group; two cases occurred in the control group.

CONCLUSION(S)

In countries in which surgical management of ETP is still done, using sublingual misoprostol postoperatively may reduce the duration and amount of bleeding.

Giant adrenal cyst in a pregnant woman: a case report

In this case report, a rare example of a pregnant woman with a huge adrenal cyst is reported. No other published reports were found to have an outcome like the present case. A 27-year-old primiparous patient admitted to our clinic with complaints of gaining weight, abdominal distension and dyspnea. On physical examination abdominal distension was prominent. She weighed 78 kg. At abdominal ultrasonography, there was an 11 week, single live fetus within the uterine cavity. There was also an approximately 30 x 40 cm sized cyst. The origin of the cyst could not be detected by ultrasonography and magnetic resonance imaging. It was suspected to originate from the ovaries. Tumor markers and other laboratory tests were normal. Laparotomy was planned. During laparotomy, it was observed that there was a huge, thin capsulated cystic lesion filling the abdomen. The uterus and bilateral ovaries were normal. Eleven liters of yellow-colored fluid was drained from the cyst. At exploration, the cyst capsule was originating from a right adrenal lodge and was extirpated. The postoperative weight of the patient decreased to 67 kg. On the third postoperative day, the patient was discharged without any problems. The pathology result of the patient was reported as an epithelial adrenal cyst. The patient did not have any problems on antenatal follow up and had a cesarean delivery at term for cephalopelvic disproportion. A 3500 g, healthy female fetus was delivered.

Raloxifene has favourable effects on metabolic parameters but has no effect on left ventricular function in postmenopausal women

In this prospective randomized study, we investigated the effect of raloxifene on the echocardiographic parameters of left ventricular diastolic and systolic function and on blood levels of lipids, homocysteine, and lipoprotein (a) in postmenopausal osteoporotic patients and compared the results with those treated with risedronate. A total of 44 women were included in the study. Patients were randomized into two groups. Twenty-two patients received raloxifene 60 mg/day (group 1), and 22 patients received risedronate 5mg/day (group 2; the control group). All patients underwent quantitative two-dimensional pulsed wave Doppler and tissue Doppler echocardiography. Levels of fasting total-C, HDL-C, LDL-C, triglycerides, homocysteine, and lipoprotein (a) were measured. All echocardiographic and biochemical parameters were assessed at the beginning of the study and after the 6-month follow-up. Demographic characteristics and baseline metabolic and echocardiographic parameters were similar in the two groups. After 6 months of the therapy, serum levels of total-C, LDL-C, and homocysteine decreased significantly (P=.04, P=.02, P=.008, respectively) in the treated group when compared with the control group. All echocardiographic measurements except a wave from level of basal interventricular septum were similar in the two groups both before and after 6 month of therapy. In the control group, a wave from level of basal interventricular septum increased significantly (P=.019). In conclusions raloxifene may decrease serum levels of total-C, LDL-C, and homocysteine in postmenopausal osteoporotic patients and raloxifene therapy seems to have no significant effect on left ventricular systolic and diastolic function.

Maspin overexpression correlates with increased expression of vascular endothelial growth factors A, C, and D in human ovarian carcinoma

The vascular endothelial growth factor (VEGF) family, including VEGFA, VEGFC, and VEGFD, plays an essential role in the angiogenesis of both pathologic and nonpathologic conditions. Maspin belongs to the serpin superfamily and has been identified as a tumor suppressor because it inhibits motility, invasion, and angiogenesis. Few studies have compared maspin with VEGF in ovarian carcinoma. Therefore, we investigated the expression and correlation of maspin, VEGFA, VEGFC, and VEGFD with the tumorigenesis of the ovary and clinicopathologic variables. Using immunohistochemistry, we examined maspin, VEGFA, VEGFC, and VEGFD expression in 60 ovarian carcinoma tissues (35 serous papillary carcinomas, 18 endometrioid carcinomas, and 7 primary ovarian mucinous carcinomas). Staining of cells was scored as +2 if more than 50% of the cells were positive, as +1 if less than 50% of the cells were positive, and as negative if none of the cells stained positive. Overexpression of maspin, VEGFC, and VEGFD was significantly associated with high tumor grade (P<.001, P=.004, P<.001, respectively), clinical stage (P=.002, .01, and .001, respectively), the presence of ascites (P<.001, P=.03, and P=.001, respectively), and the presence of metastatic lymph nodes (P=.002, P<.001, and P<.001, respectively). Maspin was correlated with VEGFA (P=.01), VEGFC (P<.001), and VEGFD (P<.001). The VEGFA score was positively correlated with high tumor grade (P=.04), lymphovascular space invasion (LVSI) (P<.001), International Federation of Gynecology and Obstetrics (FIGO) stage (P=.009), maspin, VEGFC (P=.003), and VEGFD (P=.003), but it was not correlated with the presence of ascites and metastatic lymph nodes. Maspin, VEGFC, and VEGFD are expressed in ovarian tumors with a poor prognostic parameters, and seem to play a role in ovarian cancer angiogenesis, progression, and lymph node metastases. Our results indicate that in contrast to most other carcinomas, maspin expression is directly associated with the biological aggressiveness of ovarian carcinoma. These results may offer new insights regarding the role of maspin in ovarian cancer and might also affect the diagnosis and treatment strategies.

New surgical approaches for the management of cervical carcinoma

Cervical carcinoma remains an important health problem in both developed and developing countries even though population-based screening programs are widely available. The classical surgical management of early-stage cervical carcinoma, known as radical hysterectomy (RH), was first described by Wertheim more than one hundred years ago and was then modified and re-popularized by Meigs in 1950s. The surgical principles of this operation have undergone only minor modifications and remain the basis for the surgical approach utilized by gynecologic oncologists today. However, some recent studies have questioned the role of RH due to a high rate of postoperative complications involving the pelvic autonomic nerve system and poor oncological outcomes despite postoperative adjuvant chemoradiation. During the last 2 decades, new surgical operations (radical vaginal trachelectomy, nerve-sparing hysterectomy, total mesometrial resection, laterally extended endopelvic resection, laparoscopic assisted radical vaginal hysterectomy, laparoscopic lumbo-aortic lymph node dissection, and laparoscopic pelvic exenteration) have been proposed for the management of both early- and late-stage cervical carcinoma. In this manuscript, some technical details and oncological outcomes of these new surgical approaches are summarized.

Impact of aromatase inhibitors on adhesion formation in a rat model

OBJECTIVE

To investigate the antiadhesion potential of tamoxifen and anastrozole in a rat uterine horn model.

DESIGN

Experimental animal study.

SETTING

University animal laboratory.

ANIMAL(S)

Forty-five female Wistar albino rats.

INTERVENTION(S)

We examined the effects of tamoxifen and anastrozole to reduce the extent and severity of postoperative adhesions in a rat uterine horn model: the control group received no therapy while the second and third groups received 500 mug/day tamoxifen and 0.2 mg/kg/day anastrazole, respectively, through an enteric tube, starting 5 days before surgery. These protocols were continued for 14 days after the surgery until the rats were killed.

MAIN OUTCOME MEASURE(S)

Adhesions were scored according to their extent and severity, and specimens were also evaluated and scored histologically according to the following features: inflammation, fibroblastic activities, foreign body reaction, collagen formation, and vascular proliferation.

RESULT(S)

Anastrozole had the lowest mean adhesion scores, and these scores were significantly different from those of the controls. However, there were no statistically significant differences between control and tamoxifen groups and between tamoxifen and anastrozole groups. Histologic scores were lowest in the anastrozole group, which were statistically different from those of the tamoxifen and anastrozole groups, whereas scores of the control group were not statistically different from those of the tamoxifen group.

CONCLUSION(S)

Anastrazole decreased postsurgical adhesion scores by both visual scores and histologic analyses in a rat model. Further experimental and clinical trials are required to confirm these results.

Black cohosh and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized trial

The objective of this study was to evaluate the efficacy of fluoxetine and black cohosh in the treatment of women with postmenopausal symptoms. A total of 120 healthy women with menopausal symptoms were recruited to this prospective study with a follow-up period of 6 mo. They were randomly assigned to 1 of 2 groups and were treated with fluoxetine or black cohosh. After entry into the study, patients were examined at the first, second, third, and sixth months of the treatment period. The women kept diaries in which they reported the daily number and intensity of hot flushes and night sweats. In addition, at the beginning and end of the third month, they completed questionnaires consisting of a modified Kupperman Index, Beck's Depression Scale, and a RAND-36 Quality-of-Life Questionnaire. Statistically significant differences were noted in the Kupperman Index and Beck's Depression Scale at the end of the third month in both groups compared with baseline values. In the black cohosh group, the Kupperman Index decreased significantly compared with that in the fluoxetine group by the end of the third month. On the other hand, in the fluoxetine group, Beck's Depression Scale decreased significantly compared with that in the black cohosh group. Monthly scores for hot flushes and night sweats decreased significantly in both groups; however, black cohosh reduced monthly scores for hot flushes and night sweats to a greater extent than did fluoxetine. At the end of the sixth month of treatment, black cohosh reduced the hot flush score by 85%, compared with a 62% result for fluoxetine. By the sixth month of the study, 40 women had discontinued the study--20 (33%) in the fluoxetine group and 20 (33%) in the black cohosh group. Compared with fluoxetine, black cohosh is more effective for treating hot flushes and night sweats. On the other hand, fluoxetine is more effective in improvements shown on Beck's Depression Scale.

Prediction of preterm delivery among women with threatened preterm labor

BACKGROUND/AIMS

To determine predictive values of fetal fibronectin and phosphorylated insulin-like growth factor binding protein-1 (phIGFBP-1) in cervicovaginal secretions and ultrasonographic measurement of cervical length for delivery <35 weeks in patients with uterine contractions.

METHODS

Our study included 51 women between 24 and 35 weeks' gestation with uterine contractions and 90 controls. Cervicovaginal samples were analyzed for presence of fetal fibronectin and phIGFBP-1. Cervical length was measured by transvaginal sonography.

RESULTS

Preterm birth rate was 19.6% (10/51) in the study group. Negative predictive values of fetal fibronectin, phIGFBP-1 and ultrasonographic cervical length <20 mm, and <25 mm for delivery <35 weeks were 91.9, 92.3, 91.1, and 90.5%, respectively. Positive predictive values were 50, 58.3, 100 and 66.7%, respectively. When results of fetal fibronectin/phIGFBP-1 test and ultrasonographic cervical length <25 mm were combined, specificity and positive predictive values of each test for delivery within 7 days increased.

CONCLUSION

Fetal fibronectin and phIGFBP-1 tests have approximately equivalent ability to predict delivery <35 weeks' gestation. An ultrasonographic cervical length measurement >20 mm or a negative fetal fibronectin/phIGFBP-1 test obtained from patients with uterine contractions at 24-35 weeks' gestation may avoid overdiagnosis.

Labor induction at term: a comparison of the effects of 50 microg and 25 microg vaginal misoprostol

PURPOSE OF INVESTIGATION

To compare the effects of 50 microg of vaginal misoprostol with 25 microg for labor induction at term.

METHODS

One hundred and forty-seven pregnant women with indications for labor induction and cervical Bishop's score of < or = 6 were randomly assigned to receive either 50 microg (n = 74) or 25 microg (n = 73) of vaginal misoprostol every four hours until either a Bishop's score of > or = 8 or adequate uterine contraction frequency had been achieved. Induction-to-vaginal-delivery time was considered the primary outcome measure.

RESULTS

Mean induction-to-vaginal-delivery time was significantly shorter in the 50-microg group than in the 25-microg group (526 +/- 141 min vs 745 +/- 218 min, respectively); oxytocin was administered to 65.8% of the patients in the 25-microg group and to 35.1% in the 50-microg group (p < .05). The incidence of tachysystole was significantly higher in the 50-microg group than in the 25-microg group (12% vs 2.7%, p < .05). We found no statistically significant difference between the two groups with respect to the rate of primary cesarean section, incidence of hyperstimulation syndrome, or neonatal outcome (p > .05).

CONCLUSION

Fifty micrograms of vaginally administered misoprostol is an effective and inexpensive means of inducing labor at term. Uterine tachysystole may be associated more frequently with a 50-microg dose of vaginal misoprostol than with a 25-microg dose. Clinicians must accurately document the frequency and intensity of uterine contractions before every 50-microg dose of misoprostol is administered.

How best is to discontinue postmenopausal hormone therapy: Immediate or tapered?

BACKGROUND

To evaluate the differences between the immediate and tapered cessation protocols of hormone therapy in terms of recurrence of menopausal symptoms.

MATERIALS AND METHODS

In this prospective, randomized clinical study 70 consecutive patients in whom hormone therapy was no longer preferred were recruited from the menopause clinic of a university hospital and rank randomized into two groups. In group 1 (n=35) hormone therapy was immediately discontinued and in group 2 (n=35) the medication was tapered. Every patient was questioned about vasomotor symptoms before the initiation of hormone therapy at the first visit, and then revisited at the end of 2 and 4 weeks.

RESULTS

We did not find any statistically significant difference between two protocols in terms of symptom severity and frequency at the end of 2 and 4 weeks of discontinuation. Although statistically insignificant, the symptoms tended to recur in fewer patients and in a less severe form in both groups when compared with their pretreatment status.

CONCLUSIONS

Tapering or immediate discontinuing of hormone therapy did not affect the recurrence rate and severity of menopausal symptoms at the end of 4 weeks.

COX-2 and survivin are overexpressed and positively correlated in endometrial carcinoma

OBJECTIVES

To investigate the expressions of survivin and Cyclooxygenase-2 (COX-2), and their possible correlations in the development of endometrial adenocarcinoma (EC). We also looked at their association with classical prognostic factors in EC. To our knowledge, this is the first time survivin expression is investigated in terms of its relation to COX-2 in the developmental pathway of EC.

METHODS

Archived tissue samples of 50 EC, 30 endometrial hyperplasia and 20 proliferative endometrium were selected and immunohistochemically analyzed for survivin and COX-2 expression.

RESULTS

Both survivin and COX-2 were overexpressed in hyperplasia and endometrial adenocarcinoma cases compared to proliferative endometrium, which was statistically significant (p=0.01, p=0.02, respectively). Among EC cases, survivin and COX-2 were strongly positive in 38 (76%) and 30 (60%) patients, respectively. Furthermore, we found survivin and COX-2 to be positively correlated, which was also statistically significant (p=0.0001, r=0.46). Neither survivin nor COX-2 expression was correlated with classical prognostic factors of endometrial carcinoma such as myometrial invasion, grade or lymph node metastasis (p>0.05). Neither COX-2 nor survivin had an impact on overall survival (p>0.05).

CONCLUSIONS

Both survivin and COX-2 are overexpressed, and they seem to be early events in the occurrence of EC. Moreover, protein products of these two genes are positively correlated. COX-2 and survivin might share a common molecular pathway or enhance each other's actions in the developmental pathway of EC. Molecular basis of such a relationship should be further investigated in endometrial carcinogenesis.

Lobular carcinoma of the breast metastatic to the uterus in a patient under adjuvant anastrozole therapy

This is the first report of breast carcinoma metastatic to the endometrium in a patient on adjuvant anastrozole therapy. We report a case of metastatic lobular carcinoma of the breast in a 63-year-old patient on adjuvant anastrozole therapy for 8 months. She was asymptomatic and metastatic endometrium was diagnosed after transvaginal ultrasound revealed suspicious findings along with elevated Ca 15-3 levels. As further work up showed no other metastatic sites her uterus was taken out along with her ovaries and pelvic lymph nodes. Uterine metastases should be kept in mind in asymptomatic patients on anastrozole therapy.

Expression of cyclin H in normal and cancerous endometrium, its correlation with other cyclins, and association with clinicopathologic parameters

Cyclins are known as regulatory proteins in cell cycle. Cyclin H is a part of cyclin H/Cdk7/Mat1 complex, which is necessary for cellular proliferation. This study was designed to investigate the correlation of cyclin H expression with tumorigenesis of the endometrium and clinicopathologic variables. Immunohistochemical staining using labeled streptavidin-biotin complex was performed on formalin-fixed, paraffin-embedded endometrial tissues of the proliferative, hyperplastic, and carcinomatous types. Immunostaining for cyclins A, B1, D1, D3, E, H, and cyclin dependent kinase 2 were evaluated. The expression of cyclins A, D1, D3, and H in hyperplasia was significantly more frequent than those of proliferative phase and less than those of endometrioid adenocarcinoma. The expression of cyclin H was correlated with lymphvascular space invasion and clinical stage in carcinoma but not with myometrial invasion, lymph node metastasis, and menopause status. The expression of cyclin H could be involved in the transformation of the endometrium into malignancy and might be a marker for more proliferative and malignant features. It might be one of the biomarkers for determining proliferative activity in endometrial hyperplasia and endometrioid adenocarcinoma.

Expression of survivin, PTEN and p27 in normal, hyperplastic, and carcinomatous endometrium

We aimed to investigate if expressions of survivin and p27 proteins are involved in the development of endometrioid carcinoma, along with whether there are any correlations between these proteins and loss of wild-type PTEN that is found in up to 80% of endometrial carcinomas. We also studied their correlations with classical prognostic factors and survival in endometrial carcinoma. To our knowledge, this is the first time survivin expression is investigated in endometrial hyperplasia along with endometrioid adenocarcinoma. For immunohistochemical analysis, 29 endometrioid adenocarcinoma, 38 endometrial hyperplasia, and 10 proliferative endometrium tissue samples were selected in the pathology archives. Staining of cells was scored as +2 if >50%, +1 if <50%, and negative if none were stained positive. Survivin expression increased from proliferative to hyperplasia to carcinoma cases. PTEN and p27 expressions decreased in hyperplasia and carcinoma cases with respect to proliferative endometrium. All these differences were statistically significant (P < 0.05). PTEN positively correlated to p27 (P < 0.05); however, neither was correlated with survivin. None of these genes were correlated with classical prognostic factors such as grade and myometrial invasion in endometrioid adenocarcinoma. However, mean survival was statistically significantly higher in PTEN-positive cases (46.6 vs 16.4 months) (P < 0.05). Survivin overexpression might be one of the important mechanisms in the development of endometrioid adenocarcinoma along with lost or decreased activity of PTEN and p27. However, survivin seems to exert its role in ways different from those of PTEN or p27 in the development of endometrioid adenocarcinoma. These findings on the role of survivin in endometrioid adenocarcinoma should be confirmed and the pathways through which survivin acts in endometrioid adenocarcinoma studied further with a larger sample size.

Effects of aspirin on placenta and perinatal outcomes in patients with poor obstetric history

OBJECTIVE

The aim of this study was to compare a low-dose aspirin treatment on placental and perinatal effects in the patients with poor obstetric history such as preeclampsia, intrauterine growth retardation (IUGR) in previous pregnancy.

STUDY DESIGN

This retrospective study of 86 pregnant women was conducted between April 2002 and June 2005. In this study period 364 placentas were examined and the patients with poor obstetric history such as IUGR and preeclampsia were selected. Then the patients were assigned to three groups; group 1 (n = 30) was composed of women with no risk in previous pregnancy; group 2 (n = 27) was composed of patients with poor obstetric history (e.g., preeclampsia, IUGR) who were treated with aspirin and patients in group 3 (n = 29) had poor obstetric history without any treatment (patients who were started to follow-up after 14 weeks of gestation). Patients in group 2 were treated with a low-dose aspirin (80 mg/day) as soon as a urinary pregnancy test was positive. Treatment was usually stopped at 34 completed weeks of gestation. On histopathologic examination of the placenta, uteroplacental vascular pathologic features and secondary villous damage (such as fibrinoid necrosis of desidual vessels, villous infarct, severely increased villous fibrosis, severely increased syncytiotrophoblast knotting, obliteration of the vessel lumen, severely increased villous hypervascularity) and also lesions involving coagulation (such as excessive perivillous fibrin deposition, multiple occlusive thrombi in uteroplacental vessels, avascular villi ) were examined.

RESULTS

There were no significant differences between the groups with respect to maternal age, body mass index at the first trimester and delivery. Also there were no significant differences among groups with respect to placental weight, fetal height, weight, gestational week, umbilical artery pH, pO2, pCO2 and base excess status. The incidences of preeclampsia were 3.3, 7.4, 6.8% and the incidences of IUGR were 6.7, 11.1, 6.8% in the groups, respectively (P > 0.05 for both). Although the percentages of all pathologic findings were higher in groups 2 and 3, these differences were not statistically important.

CONCLUSION

When low-dose aspirin is taken, starting at the beginning of pregnancy in patients with poor obstetric history, there are still high frequencies of uteroplacental vascular and related villous lesions persisted on placental bed. Also it has no beneficial effects on perinatal outcomes in these patients.

Expression of survivin, PTEN and p27 in normal, hyperplastic, and carcinomatous endometrium

We aimed to investigate if expressions of survivin and p27 proteins are involved in the development of endometrioid carcinoma, along with whether there are any correlations between these proteins and loss of wild-type PTEN that is found in up to 80% of endometrial carcinomas. We also studied their correlations with classical prognostic factors and survival in endometrial carcinoma. To our knowledge, this is the first time survivin expression is investigated in endometrial hyperplasia along with endometrioid adenocarcinoma. For immunohistochemical analysis, 29 endometrioid adenocarcinoma, 38 endometrial hyperplasia, and 10 proliferative endometrium tissue samples were selected in the pathology archives. Staining of cells was scored as +2 if >50%, +1 if <50%, and negative if none were stained positive. Survivin expression increased from proliferative to hyperplasia to carcinoma cases. PTEN and p27 expressions decreased in hyperplasia and carcinoma cases with respect to proliferative endometrium. All these differences were statistically significant (P < 0.05). PTEN positively correlated to p27 (P < 0.05); however, neither was correlated with survivin. None of these genes were correlated with classical prognostic factors such as grade and myometrial invasion in endometrioid adenocarcinoma. However, mean survival was statistically significantly higher in PTEN-positive cases (46.6 vs 16.4 months) (P < 0.05). Survivin overexpression might be one of the important mechanisms in the development of endometrioid adenocarcinoma along with lost or decreased activity of PTEN and p27. However, survivin seems to exert its role in ways different from those of PTEN or p27 in the development of endometrioid adenocarcinoma. These findings on the role of survivin in endometrioid adenocarcinoma should be confirmed and the pathways through which survivin acts in endometrioid adenocarcinoma studied further with a larger sample size.

Prenatal diagnosis of bilateral diaphragmatic hernia by fetal sonography

This report describes a case of prenatally diagnosed bilateral diaphragmatic hernia. At 22 weeks' gestation, ultrasound revealed a cystic structure behind the fetus's heart on the axial image at the level of the cardiac four-chamber view. This suggested a left-sided congenital diaphragmatic hernia with herniation of the stomach into the left hemithorax. However, the left-to-right midline shift of the heart was minimal, which is not typical of left-sided congenital diaphragmatic hernia. Throughout the 30th week of gestation, the right and left branches of the pulmonary artery were hypoplastic compared with the values in normal fetuses of the same gestational age. The presumptive diagnosis was bilateral congenital diaphragmatic hernia. A female newborn weighing 2900 g was delivered at 37 weeks' gestation, and she died at 7 h of age. An autopsy revealed large defects on both sides of the diaphragm. In conclusion, prenatal diagnosis of bilateral diaphragmatic hernia is possible with fetal sonography.

Gastrointestinal stromal tumors presenting as pelvic masses: report of two cases

We present two cases of gastrointestinal stromal tumors (GISTs) that presented as pelvic masses. These tumors can present diagnostic problems and they may be difficult to discover preoperatively. GISTs are neoplasms that can be diagnosed utilizing immunohistochemistry, especially detecting CD117 (c-kit) reactivity along with associated histological features. GISTs, should be considered in the differential diagnosis of ovarian tumors especially when imaging studies and rectovaginal examination findings are inconclusive and vague. Histologic diagnosis of these tumors are important considering the efficacy of tyrosine kinase inhibitor therapy after surgery in such cases.

Primary leiomyoma of the ovary in a young woman: literature review and report of a case

Ovarian leiomyoma is a rare tumor. We present a case of ovarian leiomyoma in a 32-year-old virgin with the complaint of dysmenorrhea for six months. On magnetic resonance imaging, a 6 cm x 4 cm mass in the left ovary exhibiting hypointense signals on both T1-weighted and T2-weighted images was initially considered to be fibroma and/or thecoma. However, after surgery the pathological diagnosis of the removed tumor was leiomyoma of the left ovary. The literature on this rare tumor was also reviewed.

Non-invasive management of fetal goiter during maternal treatment of hyperthyroidism in Grave's disease

There is an increased risk of fetal goiter in patients who have a history of Grave's disease and undergo propylthiouracil (PTU) treatment during pregnancy. In this report, we describe a case of a fetal goiter detected by antenatal ultrasound at the 26th week of gestation in a mother treated with PTU for Grave's disease. A 32 x 38 x 20 mm fetal goiter was detected, each lobe measured 30 x 18 x 18 mm and estimated volume was 10 cm3. Subsequently, fetal thyroid function was assessed by umbilical fetal blood sampling. Cord blood showed elevated serum TSH (40.2 mU/l) and normal concentrations of free T4 (9.5 pmol/l) and free T3 (2.6 pmol/l). There were no other ultrasonographic signs of fetal hypothyroidism. Based on the above findings, the mother's PTU dosage was reduced to 50 mg daily from a total of 150 mg and weekly ultrasonographic examinations were performed. Six weeks after the initial ultrasound, a complete regression of the fetal goiter was noted. At the 34th week of gestation, the patient was delivered due to intrauterine growth restriction and oligohydramnios and gave birth to a male, weighing 1,920 g. The newborn thyroid was not palpable and thyroid ultrasonography was normal. Cord blood TSH was normal (8.4 mU/l) and free T4 was within lower normal limit (9.03 pmol/l). Ten days later, newborn thyroid function was normal and the baby did well afterwards. In conclusion, after the evaluation of fetal thyroid status, selected cases with fetal goiter can be initially managed without intrauterine treatment.

Administration of B-group vitamins reduces circulating homocysteine in polycystic ovarian syndrome patients treated with metformin: a randomized trial

BACKGROUND

The aim of the current study was to assess the effects of B-group vitamins and folic acid administration on serum levels of homocysteine (Hcy) in patients with polycystic ovarian syndrome (PCOS) on short-term metformin treatment.

METHODS

Patients were randomly assigned to one of three treatment groups. Group 1 patients (n = 20) received metformin (850 mg twice daily); group 2 patients (n = 20) received metformin (850 mg twice daily) and B-group vitamins (vitamin B1, 250 mg; vitamin B6, 250 mg; vitamin B12, 1000 microg twice daily); and group 3 patients (n = 20) received metformin (850 mg twice daily) and folic acid (174 microg twice daily). In all groups, lipid profiles and plasma total Hcy, vitamin B12, folic acid and glucose levels were recorded at baseline and at 3 months.

RESULTS

A 26.5% increase in Hcy levels was seen after 12 weeks of metformin therapy, while 21.17 and 8.33% decreases in Hcy levels were detected when B-group vitamins or folic acid plus metformin were given respectively. There were no statistically significant differences recorded in insulin sensitivity using homeostasis model assessment in the three groups.

CONCLUSION

These findings suggest that B-group vitamins and folic acid administration counteract the Hcy-increasing effect seen with metformin therapy.

Primary ovarian leiomyosarcoma: a case report

Primary ovarian leiomyosarcomas are extremely rare tumors that comprise less than 0.1% of all ovarian malignancies. We present a case of 62-year-old postmenopausal woman with a slightly enlarged right ovary and a Color Doppler sonography resistance index (RI) measuring 0.54. The patient, after being managed with surgery alone, is alive after 14 months without any evidence of disease. This is an unusual case in that primary ovarian leiomyosarcoma was diagnosed in the setting of a slightly enlarged irregular postmenopausal ovary with a concomitant intermediate RI value on color flow Doppler evaluation. A high index of suspicion may help prevent delay in the diagnosis of this rare neoplasm.

HPV and p53 expression in epithelial ovarian carcinoma

OBJECTIVES

Human papillomavirus is the causal factor for cervical cancer. However, the role of HPV infection in ovarian cancer is unclear. This study aimed to determine the presence of human papillomavirus (HPV) in ovarian cancer tissues along with the expression of tumor suppressor gene p53. We also investigated any possible association of HPV with p53 gene mutations in ovarian carcinoma.

METHODS

Archived human ovarian cancer tissues (n = 40 cases of epithelial ovarian cancer) embedded in paraffin blocks were used. Controls were 32 non-malignant ovarian tumor tissue blocks. In situ hybridization (ISH) and immunohistochemistry (IHC) were used to detect the presence of HPV and p53 expression, respectively.

RESULTS

Of the total, 37.5% (n = 15) of malignant and 28.1% (n = 9) of benign ovarian tumors were positive for HPV (OR: 1.5 CI: 0.5-4.1, p = 0.4). The difference was not statistically significant. However, p53 was detected in 72.5% (n = 29) of malignant cases compared to 37.5% (n = 12) of benign cases (OR: 4.3 CI: 1.6-11.9, p = 0.003). Furthermore, a positive correlation between HPV and p53 expressions in ovarian cancer tissue samples was detected (r = 0.47, p = 0.001).

CONCLUSIONS

HPV does not seem to be a major component in the development of ovarian carcinoma, nevertheless HPV positivity seems to contribute to the pathogenesis in at least some ovarian carcinoma cases by way of interaction with tumor suppressor p53.

Pelvic retroperitoneal paraganglioma mimicking an ovarian mass

A 75-year-old hypertensive woman was referred with ultrasound findings of a 40 x 35 mm semi-solid right adnexal mass and right hydroureteronephrosis. She complained of headache and right-sided back pain. Computed tomography demonstrated a cystic adnexal mass that did not appear to originate from the right ovary and grade 2 hydroureteronephrosis. Magnetic resonance imaging indicated that the mass originated from the right ovary. Tumor markers were in the normal range. Exploratory laparotomy was performed to determine the origin of the lesion, and revealed a retroperitoneal mass obstructing the right ureter. The mass was completely removed and and the histopathologic diagnosis was paraganglioma.

Angular pregnancy

Angular pregnancy, a type of cornual pregnancy, is a rare obstetric complication that can be life-threatening. In this situation, the embryo is implanted in the lateral angle of the uterine cavity, medial to the uterotubal junction and round ligament. Angular pregnancy must be distinguished from interstitial pregnancy, in which the embryo is implanted lateral to the round ligament. The report presented here describes a case of angular pregnancy that was diagnosed by endovaginal ultrasonography and magnetic resonance imaging. Laparoscopy can be useful for guiding dilatation and curettage in angular pregnancies, and may circumvent the need for invasive surgery or hysterectomy.

Elevated plasma homocysteine levels in gestational diabetes mellitus

OBJECTIVE

This prospective study investigated the occurrence of hyperhomocysteinemia in a population of patients with gestational diabetes. The aim was to determine whether elevated plasma homocysteine is associated with gestational diabetes in Turkish women.

STUDY DESIGN

This prospective controlled study was conducted in the Department of Obstetrics and Gynecology of the Baskent University Faculty of Medicine between April 2002 and June 2003, and involved 304 Turkish women with uncomplicated pregnancies who were at 24-28 weeks gestation. The women in the study were assigned to one of three groups according to the results of the 50-g glucose screening and the oral glucose tolerance test (OGTT): group 1 comprised women who had normal glucose levels (< or = 135 mg/dL) after the 50-g challenge; group 2 comprised women with abnormal screening test results (> 135 mg/dL) but normal OGTT results; and group 3 comprised patients with gestational diabetes mellitus (GDM) according to the OGTT. Levels of fasting glucose, homocysteine, vitamin B(12) and folic acid, total cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides, low density lipoprotein (LDL) cholesterol and very low density lipoprotein (VLDL) cholesterol levels were measured in the three groups. Levels of insulin sensitivity were calculated using the homeostasis model assessment (HOMA) formula.

RESULTS

The mean level of homocysteine in group 1 was significantly lower than the levels in groups 2 and 3 (p < 0.001) The mean triglyceride and VLDL levels in group 3 were significantly higher than the corresponding levels in group 1 (p < 0.05 for both). There were no significant differences among the groups with respect to levels of total cholesterol, vitamin B(12), folic acid, creatinine, fasting glucose or insulin. The mean HOMA value in group 3 was significantly higher than that in group 1 (p < 0.05). Only the blood glucose level after the 50-g glucose screening [p = 0.000, 95% confidence interval (CI) 0.009-0.027] had a significant correlation with homocysteine levels.

CONCLUSION

In this prospective study of Turkish women, we found that patients with gestational diabetes and women with abnormal screening test results (> 135 mg/dL) but normal OGTT results have higher homocysteine levels than normal pregnant women. This increased level seems to be related to an abnormal 50-g test but not to insulin resistance. Further investigations are needed to follow up for these patients in the postpartum period and later in their life.

Well-differentiated papillary mesothelioma complicating endometrial carcinoma: a case report

We present a case of well-differentiated papillary mesothelioma discovered during staging surgery for endometrial carcinoma in a 50-year-old postmenopausal woman. In case of simultaneous well-differentiated papillary mesothelioma (WDPM) and endometrial carcinoma, the surgeon may be mistaken by considering peritoneal implants as tumor metastasis. This situation may result in overtreatment of the patient. Thus a thorough pathologic examination of the specimens taking care not to miss any areas of invasion, and utilizing immunohistochemical analysis when necessary are important to avoid such mistakes. To our knowledge this is the first report of the simultaneous occurrence of endometrial carcinoma in conjunction with diffuse WDPM of the peritoneum.

Management of advanced-stage primary carcinoma of the fallopian tube: case report and literature review

Primary carcinoma of the fallopian tube is a very unusual gynecologic malignancy that accounts for less than 1% of all malignancies of the female genitalia. A 55-year-old, gravida 7, para 3 woman presented with no gynecologic complaints other than backache. TVS demonstrated a 35 x 25 mm heterogeneous mass that was not clearly separated from the left ovary, and another 31 x 14 mm cystic septated lesion in the left ovary region. Pelvic MRI demonstrated a 35 x 35 x 20 mm left adnexal mass that enhanced with contrast and a neighboring tubular-cystic mass. Upper and lower gastrointestinal endoscopy revealed no malignancy. Serum CA 125-level was merkedly elevated at 369 U/ml (normal < 35 U/ml). Laparotomy revealed left hydrosalpinx and a papillary-fimbrial mass. Pelvic lymph node metastases were observed. Frozen-section analysis identified the mass as a serous adenocarcinoma. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, pelvic and para-aortic lymph node dissection, and peritoneal washing were performed. The definitive histopathological diagnosis was primary serous adenocarcinoma of the fallopian tube with six of 25 lymph node biopsies showing metastasis. Six cycles of paclitaxel (175 mg/m2) plus cisplatin (75 mg/m2) combinatin chemotherapy were administered with 3-week intervals between cycles. Second-look laparotomy was performed; there was no evidence of disease. At the time of writing 12 months after the second-look laparotomy, she was still disease-free.

Sclerosing stromal tumor of the ovary: a case report

Sclerozing stromal tumor of the ovary is an extremely rare neoplasm occurring predominantly in the second and third decades of life. Most patients have menstrual irregularities and pelvic pain. Infertility and endometrial pathology have also been described. A 34-year-old woman presented with hirsutism and oligomenorrhea of three months duration. Ultrasound examination showed a heterogeneous right ovarian tumor consisting of predominantly solid tissue with several loculated cysts. On T2-weighted pelvic MR images, signal intensities of the cystic components were high and those of the solid components were heterogeneous, ranging from intermediate-high to high. Dynamic MRI marked early enhancement of solid components in the right ovary. The specimen obtained from endometrial curettage showed proliferative endometrium. Preoperative serum levels of tumor markers were in normal range: preoperative serum levels of testosterone (T) (2.42 ng/ml; normal for adult females 0.1-0.8 ng/ml) and dehydroepiandrosterone-sulphate (DHEA-S) (232.4 microg/dL; normal for adult female, 35-430 microg/dL) were measured and the T value was found increased. At laparotomy, a left ovarian mass was found attached to the right infundibulopelvic ligament and a left oophorectomy was performed. The mass was described as benign by frozen analysis. Definitive histopathological diagnosis was sclerozing stromal tumor of the ovary (SST). The histologic features included a pseudolobular pattern with focal areas of sclerosis and a two-cell population of spindled and polygonal cells. Immunohistochemical studies showed positive smooth muscle actin and negative cytokeratin, keratin, S100 and desmin. The T value decreased postoperatively (0.57 ng/ml).