Can preoperative neutrophil to lymphocyte and platelet to lymphocyte ratios predict cervical stromal involvement in endometrioid endometrial adenocarcinoma?

PURPOSE

To evaluate the possible relationships between preoperative inflammatory markers [neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)] and cervical stromal involvement in endometrioid endometrial adenocarcinoma.

MATERIALS AND METHODS

Charts and pathology results of 639 women who were operated on for endometrioid endometrial adenocarcinoma between 2000 and 2013 in the present clinic were retrospectively reviewed. Demographic, laboratory, and clinical parameters were evaluated.

RESULTS

118 women (18.4%) had cervical stromal involvement. Lymph node positivity was significantly more frequent in the cervical stromal involvement group (p < 0.001). A threshold value of 2.41 for NLR had a sensitivity of 62.7%, specificity of 60.1%, PPV of 61.1%, and NPV of 61.8% for the presence of cervical stromal involvement. In multivariate analysis, increased NLR had a significant predictive value for cervical stromal involvement (p = 0.006, OR = 2.03), although PLR remained non-significant (p = 0.77, OR = 1.08).

CONCLUSIONS

The preoperative NLR assessment is a significant predictor for cervical stromal involvement in endometrioid endometrial adenocarcinoma.

The surgical outcomes of abdominal radical trachelectomy: does transrectal ultrasonography determine the cervical incision site during surgery?

PURPOSE

To evaluate the surgical outcomes of abdominal radical trachelectomy(ART) and the efficacy of transrectal ultrasonography in determining the upper end of cervical incision during this operation.

MATERIALS AND METHODS

ART was performed in five patients with early-stage cervical cancer in the present clinic. In the first three patients, uterine corpus was transacted blindly at a level of approximately five mm below the internal os. In the last two patients, the authors performed transrectal ultrasonography before vaginal incision to evaluate the distance between upper margin of tumoral mass and internal os of cervical canal.

RESULTS

Mean follow-up was 21 months. During this period, menstrual abnormality occurred in three patients. The two patients in which transrectal ultrasonographies were taken intraoperatively had 9- and 12-mm postoperative cervical canal length and both of them were asymptomatic postoperatively.

CONCLUSIONS

ART is usually associated with menstrual abnormality at late postoperative period and transrectal ultrasonograph during this procedure may decrease postoperative morbidity.

The effect of long-term use of progesterone therapy on proliferation and apoptosis in simple endometrial hyperplasia without atypia

The aim of this study was to evaluate the effect of long-term use of progesterone treatment on proliferation and apoptosis in simple endometrial hyperplasia without atypia. In this prospective control study, endometrial tissue samples of 19 patients with simple endometrial hyperplasia without atypia (group 1), posttreatment biopsy materials of the patients after 3 months of cyclic progesterone treatment with noretisterone for 10 days (group 2), and 18 endometrial biopsy materials of the control group (group 3) were examined for proliferative and apoptotic activities. There was a statistically significant difference between the median values of the proliferative index of the three groups (P = 0.000). The proliferative index was significantly higher in the endometrial hyperplasia group than in posttreatment group (P = 0.000). But there was no significant difference between posttreatment group and control group. The median value of apoptotic activity was significantly different between three groups (P = 0.000). Apoptotic index was highest in hyperplasia group. A significant decrease in apoptosis was observed after the progesterone treatment (P = 0.002). The lowest apoptotic activity was detected in the control group. In conclusion, 3 months of cyclic progesterone treatment reduces both proliferative and apoptotic activities in endometrial tissue with simple hyperplasia.

Skin metastasis in ovarian carcinoma

We report a case of 69-year-old woman who presented with pleural metastasis of a serous papillary adenocarcinoma of the ovary. After chemotherapy and surgery, she had 2 years disease-free survival. After this period of time, she presented with a swollen leg, a cellulitis-like syndrome and erythematous nodules at lower abdominal wall and upper leg skin. The skin biopsy revealed metastasis of adenocarcinoma in the dermis. She died after 4 months of the diagnosis of the skin metastasis. In 20 years experience in our unit, it is the first time that we recognize a cutaneous metastasis in ovarian cancer.

Skin metastasis in ovarian carcinoma

We report a case of 69-year-old woman who presented with pleural metastasis of a serous papillary adenocarcinoma of the ovary. After chemotherapy and surgery, she had 2 years disease-free survival. After this period of time, she presented with a swollen leg, a cellulitis-like syndrome and erythematous nodules at lower abdominal wall and upper leg skin. The skin biopsy revealed metastasis of adenocarcinoma in the dermis. She died after 4 months of the diagnosis of the skin metastasis. In 20 years experience in our unit, it is the first time that we recognize a cutaneous metastasis in ovarian cancer.

Radical versus conservative surgery for vulvar carcinoma

OBJECTIVE

The comparison of the radical and conservative surgical approaches for vulvar carcinoma in relation to the rate of recurrence and complications.

METHODS

The records of invasive vulvar carcinoma cases were retrospectively reviewed in Istanbul University, Cerrahpasa School of Medicine, Gynecologic Oncology Division and Social Insurance Institution, Ankara Maternity Hospital, Gynecologic Oncology Department. Surgically treated cases with squamous histology were divided into radical vulvectomy and conservative procedures groups and were compared with respect to recurrence, complications, and disease-free survival.

RESULTS

One hundred thirteen cases of invasive vulvar carcinoma cases were of squamous histopathology and 92 of these were surgically treated. The rate of local recurrence was lower in the radical vulvectomy group (25%) compared to conservative procedures groups (42.5%; p>0.05). The complication rates were comparable between the radical vulvectomy and conservative procedures groups (32.7% versus 35%, respectively; p>0.05). At the end of five years of the follow-up, the disease-free survival rates were 51.5% in radical vulvectomy group versus 35.7% in conservative procedures group (p>0.05).

CONCLUSION

The rate of recurrence, complication, and disease-free survival are similar for the radical vulvectomy and the conservative procedures. Deciding the surgical strategy for vulvar carcinoma should depend on the experience of the surgeon for the short-term adequate results.

Vascular endothelial growth factor in adnexal masses

OBJECTIVES

To determine cyst fluid and serum vascular endothelial growth factor (VEGF) concentrations in patients with ovarian masses and to investigate the efficiency of this modulator in the clinical management of cystic pelvic masses.

METHODS

Needle puncture for cyst fluid aspiration were performed on 88 cystic ovarian masses intraoperatively. Forty-five patients with benign and 43 patients with malignant ovarian pathology were analyzed for cyst fluid and serum VEGF concentrations. Both cystic fluid and serum VEGF concentration were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Cyst fluid VEGF levels of malignant cysts (40.65+/-17.69 ng/ml) were significantly higher than those of benign cysts (12.53+/-6.13 ng/ml; P<0.001). Similarly, higher serum VEGF concentrations were found in patients with malignant disease (0.72+/-0.17 ng/ml) compared with benign cysts (0.33+/-0.11 ng/ml; P<0.001). A statistically significant correlation was observed between cyst fluid and serum VEGF levels in both malignant and benign cysts. For serum VEGF, at a cut-off value of 0.41 ng/ml; sensitivity, specificity, PPV, and NPV were 95%, 78%, 80% and 95%, respectively. No significant correlation between cyst fluid VEGF concentration and tumor stage or grade could be found.

CONCLUSIONS

Significantly higher concentrations of VEGF are present in cyst fluid and serum of patients with malignant ovarian cysts compared with benign ovarian ones. There is no relation between VEGF and tumor stage or grade.

Primary fallopian tube carcinoma: a retrospective multicenter study

PURPOSE

This retrospective multicenter study aimed to assess the survival and prognostic factors of primary fallopian tube carcinoma.

METHODS

The medical records of 29 patients with fallopian tube carcinoma from two centers were reviewed for age, stage, surgical intervention, relapse and survival.

RESULTS

The mean age of the patients was 56 years (range, 37-76). Six patients were in Stage I (20.7%), eight cases in Stage II (27.6%), nine cases in Stage III (31%) and two cases in Stage IV (6.9%). Data on stage was not available in four cases (13.8). Fifteen patients underwent lymph node evaluation. The median follow-up was 29 months (range, 3-122). The median survival was 95 months with a 5-year survival rate of 69.7%. The median progression-free survival was 76 months with a 5-year survival rate of 51.8%.

CONCLUSION

Age, stage and lymphadenectomy were found to be significant prognostic factors on overall survival.

Extensive pelvic endometriosis with malignant change in tamoxifen-treated postmenopausal women

The aim of this study was to document a case of tamoxifen-associated extensive pelvic endometriosis and attract the attention to this side effect of tamoxifen use in the postmenopausal patient. A 74-year-old woman with a history of breast carcinoma who received tamoxifen therapy for 2 years was admitted with uterine bleeding. Hysteroscopic polypectomy revealed a hyperplastic polyp. Extensive pelvic endometriosis was detected at the operation and due to dense adhesions, subtotal hysterectomy and bilateral salpingo-oophorectomy were performed. The patient continued to use tamoxifen. A supracervical pelvic mass was detected 14 months later. The cervix, rectum, and the accompanying mass were resected. Histopathologic examination revealed endocervical adenocarcinoma and endometriosis involving cervix uteri and the rectal muscular wall. The patient had two normal cervical smears within the last 3 years and no abnormal appearance was detected within the cervical canal in the hysteroscopic examination. As cervical cancer occurred in a short period, it might be speculated that tamoxifen might have stimulated the proliferative and mitotic activity of cervical endometrial tissue which has progressed into invasive cancer in time.

CD28/CTLA4 gene region on chromosome 2q33 confers genetic susceptibility to celiac disease. A linkage and family-based association study

Celiac disease (CD) is a common small intestinal injury caused by sensitivity to gliadin in genetically-predisposed individuals. The only susceptibility locus established is the HLA-DQ. We tested whether the chromosomal region of the CD28/CTLA4 genes on 2q33 is linked to CD. These genes encode receptors regulating the T-lymphocyte activation. Recently, this gene region was reported to be linked to the susceptibility to many autoimmune diseases, including insulin-dependent diabetes (IDDM12locus). It is thus an obvious candidate locus also for CD, since the intestinal injury is mediated by the immune system. Genetic linkage between seven marker loci in this gene region and CD was studied in 69 Finnish families. In the multipoint linkage analysis, the highest non-pararametric linkage score (NPL) was 1.75 (P=0.04) for D2S116, suggesting weak linkage for this candidate locus. To evaluate this finding, an additional 31 families were typed for all markers. In the combined set of 100 families the NPL score for marker D2S116 was 2.55 (P=0.006) and for other markers 1.90-2.47 (P=0.029-0.007), supporting genuine linkage at this region. Significantly, locus D2S116 also showed a clear allelic association in these 100 families (P=0.0001). The transmission/disequilibrium test (TDT) for locus D2S116 gave preliminary evidence for preferential maternal non-transmission of allele *136 to patients (TDTmax=8.3; P<0.05). No paternal deviation was found suggesting that the effect of the locus might be mediated by a sex-dependent factor protective against CD. Our results indicate that the CD28/CTLA4 gene region can contain a novel susceptibility locus for CD and support the hypothesis that CD has an immune system-mediated component. Like the HLA, the CD28/CTLA4 genes appear to be associated with genetic susceptibility to various autoimmune diseases.

A strong prognostic variable in endometrial carcinoma: flow cytometric S-phase fraction

BACKGROUND

The purpose of this study was to determine the role of flow cytometric S-phase fraction as a prognostic factor in patients with endometrial adenocarcinoma.

METHODS

The study included 80 patients with endometrial adenocarcinoma of endometrioid type who were followed regularly between 1984-1995 in the Department of Obstetrics and Gynecology at Cerrahpasa Faculty of Medicine in Istanbul, Turkey. The method employed for the flow cytometric analysis was modified from Hedley et al.

RESULTS

The S-phase fraction was identified as the most significant variable associated with death from endometrial carcinoma of endometrioid type by the Cox proportional hazards model. The risk of death was significantly higher in patients with S-phase values greater than 20%. Aneuploidy and DNA indexes were also significant prognostic variables.

CONCLUSIONS

The S-phase fraction is considered to be a significant prognostic variable in identifying those patients with endometrial carcinoma who have a poor prognosis. The authors believe that S-phase fraction distinguishes those patients who may benefit from additional treatment approaches.

What should be the cut-off level of serum CA125 to evaluate the disease status before second-look laparotomy in epithelial ovarian carcinoma?

To assess the predictive value of serum CA125 level prior to second-look laparotomy in epithelial ovarian carcinoma, 45 patients who were clinically or radiologically tumor-free prior to a second-look laparotomy were studied. Serum CA125 levels were measured 10 days prior to the operation, and were compared with the surgico-pathological results. Twenty-eight (62%) patients were found to have tumor at surgery. The serum CA125 levels were > or = 35 U ml-1 (42%) patients. Tumors were found in 14 (74%) of these 19 patients. Although a serum CA125 level > or = 35 U ml-1 was a strong predictor of the presence of an intraperitoneal tumor, a level <35 U ml-1 was not predictive of a tumor-free state. When the cut-off level was accepted as 20 U ml-1, 28 patients (62%) were found to have elevated CA125 level. The sensitivity, the specificity, the positive and negative predictive value and the false negative ratio were calculated as 79%, 65%, 79%, 65% and 21% respectively. The threshold value for a raised CA125 level was considered and a lower level of 20 U ml-1 was suggested as a cut-off level prior to second-look laparotomy in evaluating patients with known epithelial ovarian cancer.

Ultrasonographic appearance of endometrium in postmenopausal breast cancer patients receiving tamoxifen

OBJECTIVES

To assess the ultrasonographic appearance and associated pathological changes of the endometrium in postmenopausal breast cancer patients with tamoxifen therapy.

STUDY DESIGN

Forty-eight postmenopausal breast cancer patients receiving 20 mg/day tamoxifen for 6-84 months (mean 29) and 38 control breast cancer patients without any hormonal treatment were examined by transvaginal ultrasonography and endometrial biopsy. Any thickening of the endometrium with cystic formations or homogeneous endometrial thickening > 10 mm detected by ultrasonography was defined as abnormal endometrial appearance. Homogeneous endometrial thickening < 10 mm without cystic formations was accepted as normal. Statistical analysis was performed using the Student's t-test and Mann-Whitney U test.

RESULTS

The two groups were similar in age and menopausal period. The patients on tamoxifen therapy had a thicker endometrium (8.6 +/- 6.6 mm) than the non-treated women (4.8 +/- 3.1 mm), which was found to be a statistically significant difference (P < 0.01). The sonographic evaluations showed abnormal endometrial appearance in 8 cases of tamoxifen treated women while the others revealed homogeneous thickness < 10 mm without cystic formations or a thin linear echo with or without fluid in the endometrial cavity. All 8 patients with cystic appearance had endometrial thickness > 10 mm. Only 1 patient had endometrial cancer on biopsy and no pathology was observed in the remaining 7 patients. In the control group, only 1 patient had abnormal ultrasonographic finding who had insufficient endometrial tissue on biopsy.

CONCLUSIONS

Tamoxifen can produce a sonographic image of the endometrium that resembles endometrial neoplasia. It is suggested that the discrepancy between the sonographic findings and histology may be the result of the stromal edema of the endometrium from tamoxifen treatment. Until more data are gathered, all postmenopausal breast cancer patients who are being treated with tamoxifen should have a periodic ultrasonographic examination and those presenting with a sonogram suggestive of endometrial pathology should undergo biopsy.

Case report: liver function abnormalities in a severe case of hyperreactio luteinalis

Rare causes of liver dysfunction in pregnancy may pose a challenge to the consulting gastroenterologist or hepatologist from both the diagnostic and therapeutic standpoints. We describe here liver function abnormalities in a case of hyperreactio luteinalis with light and electron microscopic findings.