Showing papers in "European Journal of Gynaecological Oncology in 2007"

Robotic surgery in gynecology.

Abstract: Robotic technology is nothing more than an enhancement along the continuum of laparoscopic technological advances and represents only the beginning of numerous more forthcoming advances. It constitutes a major improvement in the efficiency, accuracy, ease, and comfort associated with the performance of laparoscopic operations. Instrument articulation, downscaling of movements, absence of tremor, 3-D image, and comfort for the surgeon, assistant and scrub nurse are all new to the practice of laparoscopy. In our hands, robotic operative times for simple and radical hysterectomy are shorter than those obtained by conventional laparoscopy. Robotic technology is preferable to conventional laparoscopic instrumentation for the surgical treatment of gynecologic malignancies and most operations for benign disease of certain complexity such as hysterectomy myomectomy, and invasive pelvic endometriosis.

Expression of gelatinase (MMP-2 and MMP-9) and cyclooxygenase-2 (COX-2) in endometrial carcinoma.

Abstract: Objective: Matrix metalloproteinases (MMPs) are key players in the degradation of extracellular matrix and basement membranes, and are thus important in tumor invasion. Gelatinases (MMP-2 and MMP-9) in particular are prognostic factors in many solid tumors. In this study the immunohistochemical expression of both COX-2 and matrix metalloproteinases has been shown for the first time in endometrium carcinoma. Methods: Forty-two endometrial carcinoma tissues were immunostained for MMP2 antibody (1:100, Rabbit polyclonal), MMP9 antibody (1:100, Rabbit polyclonal) and CoX2 antibody (1:100, Epitope specific rabbit antibody). Results: 90.5% of the cases were positive for MMP-2 and MMP-9, and 83.3% of the cases were positive for COX-2. A statistically significant association was found between COX-2 overexpression and FIGO stage (p = 0.001). A positive correlation was also found with histological grade (p = 0.006), myometrial invasion (p = 0.033), vascular invasion (p = 0.017), and lymphatic invasion (p = 0.007). A positive correlation was found between MMP-2 overexpression and vascular and lymphatic invasion (p = 0.030 and p = 0.003, respectively). MMP-9 overexpression was also found to be correlated with vascular and lymphatic invasion (p = 0.001 and p = 0.012, respectively). Furthermore, there was a statistically significant correlation between MMP-2 and MMP-9 overexpression (p = 0.0001). Conclusion: The results showed that COX-2, MMP-2 and MMP-9 were expressed in a high percentage of primary endometrial carcinomas and their expressions may be associated closely with parameters of tumor aggressiveness.

M2-PK as a novel marker in ovarian cancer. A prospective cohort study.

Abstract: Background: Pyruvate kinase isoenzyme M2-PK is instrumental to tumour metabolism and hence over-expressed in tumour cells leading to detectable plasma concentrations. Objectives: To assess the degree of association between M2-PK plasma concentrations and ovarian cancer and to determine the cut-off values for its sensitivity and specificity for differentiating between benign and malignant ovarian disease. Settings: The Gynaecological Cancer Centre at both King's College and St. Thomas' Hospitals, London, UK. Methods: Patients with suspected ovarian cancer referred to the above centre were recruited prospectively during the years 2004-2005. Blood samples were collected before surgery for plasma M2-PK assays. Results were assessed with respect to cancer diagnosis, patient and tumour characteristics. Statistical analysis including the receiver operator characteristic (ROC) curve was performed using Analyse-It® and SPSS V13®. Results: 100 patients with age range 14-88 years and a median of 57 years were recruited in the study. Of whom 52 were diagnosed with invasive ovarian cancer. Of these 35 (67%) were Stage III and above with two secondary tumours. M2-PK was not related to patient age (p = 0.43). There was a significant correlation between CA125 and M2-PK (p < 0.001). The mean M2-PK concentration in cancer patients was 52 U/ml versus 27 U/ml in patients with benign conditions (p < 0.001). At a cut-off value of 22 U/ml the sensitivity of M2-PK for detecting cancer was 70% with a specificity of 65%. Conclusion: M2-PK was significantly raised in ovarian cancer patients, however its role in clinical practice needs further evaluation.

Hysteroscopy with directed biopsy versus dilatation and curettage for the diagnosis of endometrial hyperplasia and cancer in perimenopausal women.

Abstract: Background The present study was undertaken to compare the effectiveness of dilatation and curretage (D&C) with hysteroscopy and guided biopsy (H+B) for the collection of endometrial samples adequate for histological examination in perimenopausal women at risk of endometrial hyperplasia or cancer. Methods We performed hysteroscopy and biopsy followed by dilatation and curettage in 734 patients with abnormal perimenopausal bleeding or sonographically revealed endometrial pathology. Two hundred and ninety-two patients in whom lesions were totally removed during hysteroscopy were excluded from further study. Results Using both methods we disclosed 64 cases of endometrial polyps, 60 cases of endometrial hyperplasia, and 49 cases of endometrial cancer. Hysteroscopy left just four cases of endometrial pathology undiagnosed as opposed to 21 cases using dilatation and curettage. Histology could not be performed on material obtained with hysteroscopy in four cases and with curettage in 23 cases. Conclusions 1) Hysteroscopy with directed biopsy is more sensitive in disclosing all types of uterine lesions than dilatation and curettage. 2) Curettage done after hysteroscopy and directed biopsy does not improve the detection of endometrial cancer.

Prediction of myometrial invasion in patients with endometrial carcinoma: comparison of magnetic resonance imaging, transvaginal ultrasonography, and gross visual inspection.

Abstract: This study evaluated the accuracy of magnetic resonance imaging (MRI) and transvaginal ultrasonography (TVUS) in preoperative detection of myometrial invasion by endometrial cancer. We also evaluated the results of gross visual inspection (GVI) of surgical specimens compared with histopathological diagnosis. One hundred and seventy-seven women underwent preoperative pelvic MRI, TVUS, and intraoperative GVI. Myometrial tumor invasion was evaluated histologically and classified as absent (depth a), superficial (depth b: 50% invasion). The accuracy of MRI, TVUS, and GVI were 64.0, 66.9, and 63.8%, respectively. The positive predictive values of of each modality for depth a were 52.6, 51.4, and 52.2%, respectively. The accuracy of each in detecting deep myometrial invasion (depth c) were 84.0, 86.9, 83.1%. Although evaluation of depth a was limited with all modalities, MRI and TVUS were shown to be reliable for preoperative evaluation of deep myometrial invasion. The high accuracy of these three methods suggests that they are useful either interchangeably or in combination.

Supraclavicular lymph node metastases in cervical cancer.

Abstract: Purpose of investigation: To evaluate the outcome and prognostic factors of patients with supraclavicular lymph node (SCLN) involvement at primary diagnosis. Methods: We reviewed the medical records of cervical cancer patients primarily treated at Chang Gung Memorial Hospital between 1987 and 2005. Thirty-three patients with histologically confirmed SCLN metastasis at primary diagnosis were eligible for analysis. Clinical and pathological features were analyzed for association with outcome. Results: The 3- and 5-year survival rates of patients with SCLN metastasis were 16.5% and 16.5%, respectively. Multivariate analysis showed the serum level of squamous cell carcinoma antigen (SCC-Ag) < 15 ng/ml at initial diagnosis (p = 0.021) and staging/restaging including [ 18 F] fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) (p = 0.006) to be associated with a better prognosis. Conclusion: Primary SCLN metastasis in cervical cancer is not incurable. The benefit from PET findings might help in selecting appropriate patients for curative primary and/or salvage treatment.

Management of vulvar melanoma and review of the literature.

Abstract: Background: Vulvar melanoma represents a rare group of malignancies and is the second most common vulvar malignancy. Treatment options range from local excision of the tumor and sentinel lymph node dissection to radical resection involving en bloc vulvectomy and inguinofemoral lymphanedectomy. Vulvar melanomas have an overall poor prognosis, and there is lack of consensus in the published literature regarding treatment options. Objective: To discuss the management of vulvar melanomas through review of the actual literature. Methods: Identification of studies through computerized searches (January 2006) was conducted using MEDLINE (1966 to present), the Cochrane Central Register of Controlled Trials, the National Research Register and the Medical Research Council's Clinical Trials Register. The medical subject headings and text words used were: vulvar melanoma, malignant, management, case report, and therapy. The literature review was done over the past 36 years. Result: Results of these primary retrospective series have shown no improvement in the overall recovery or disease survival rates. Conclusion: Patients with malignant melanoma are often diagnosed at 70 years of age with multiple comorbidities. Less radical surgery presents a more realistic option for many patients without decreasing their survival rates. Surgery is still the gold standard of treatment and offers the best available treatment for controlling and potential curing of malignant melanomas. However, the whole concept of therapy should be tailored to meet the specific needs of individual patients.

Evaluation of abnormal uterine bleeding by transvaginal 3-D hysterosonography and diagnostic hysteroscopy.

Abstract: Aim To compare 3-D hysterosonography (3-DHS) and diagnostic hysteroscopy in women with abnormal uterine bleeding. Materials and methods Of 248 women with abnormal uterine bleeding who were referred to our department, 3-D hysterosonography and hysteroscopy were performed in 242 women and the results were estimated. In six women 3-DHS could not performed because of cervical stenosis. Sensitivity and specificity of 3-DHS compared to those of hysteroscopy. Results From the 242 women who underwent examination, we found 30 patients with polyps, 22 with myomas, four with mullerian anomalies, ten with endometrial cancer, 12 with adhesions and 165 with a normal uterine cavity. There was agreement between the two methods in 28 cases of polyps, 22 cases of myomas, four cases of mullerian anomalies, ten cases of endometrial cancer, eight cases of adhesions and in 165 cases of normal endometrium. The sensitivity and specificity of 3D hysterosonography was 93.5% and 99.4%, respectively, with a positive prognostic value (PPV) of 98.6% and a negative prognostic value (NPV) of 97%. The sensitivity and specificity of hysteroscopy was 98.7% and 99.4%, respectively, with a PPV of 98.7% and a NPV of 99.4%. Conclusions Three-D hysterosonography accurately assessed intrauterine pathology.

Diabetes mellitus is a multivariate independent prognostic factor in endometrial carcinoma: a clinicopathologic study on 313 patients.

Abstract: Objective The aim of this study was to analyse the influence of diabetes mellitus as a prognostic factor for overall survival in endometrial cancer. Materials and methods Charts were reviewed from patients with endometrial carcinoma from 1985 to 2003. Data on clinicopathologic variables, adjuvant treatment, site of recurrence and survival were collected. The chi-square test was used to examine associations between variables. The Kaplan-Meier method was used for survival analysis and Cox's proportional hazards model for multiple regression analysis. Results Multivariate analysis revealed that diabetes mellitus, FIGO stage and depth of myometrial invasion were significantly associated with overall survival.

Prognostic factors affecting disease-free survival in early-stage cervical cancer patients undergoing radical hysterectomy and pelvic-paraaortic lymphadenectomy.

Abstract: Objective This study was performed to identfy surgical and histopathologic prognostic factors that could predict 5-year disease-free survival (DFS) after patients underwent radical hysterectomy and pelvic-paraaortic lymphadenectomy for FIGO Stage I-II cervical carcinoma. Methods A retrospective review was performed for all patients undergoing primary radical hysterectomy and pelvic-paraaortic lymphadenectomy for Stage I-II cervical cancer at Ankara Oncology Hospital from 1995 to 2000. Clinical and pathologic variables including age, tumor size (TS), clinical stage, depth of invasion (DI), lymphovascular space involvement (LVSI), cell type, tumor grade, lymph node metastases (LNM), parametrial involvement, surgical margin involvement and pattern of adjuvant therapy were analyzed using univariate analyses. DFS was performed by the Kaplan-Meier method and the log-rank test. Independent prognostic and predictive factors affecting DFS were assessed by the Cox proportional hazard method. Results Ninety-three patients underwent primary type III radical hysterectomy and pelvic-paraaortic lymphadenectomy. Five-year DFS was 87.1%. LVSI, parametrial involvement and grade were the prognostic factors that independently affected survival. DFS was not significantly different for age, disease status of the surgical margins, tumor size, depth of invasion, cell type, pelvic lymph node metastases and adjuvant radiotherapy. Conclusions LVSI, parametrial invasion and histologic grade 2-3 were independent prognostic factors in early-stage cervical cancer patients. Adjuvant radiotherapy in these patients provides no survival advantage.

Successful spontaneous pregnancy in a patient with rectal carcinoma treated with pelvic radiotherapy and concurrent chemotherapy: the unique role of laparoscopic lateral ovary transposition.

Abstract: Concurrent administration of external beam pelvic radiotherapy (RT) and chemotherapy (CT) is an effective treatment modality for rectal cancer. In adults in reproductive age, one of the most important side-effects resulting from this treatment is gonadal toxicity. Fortunately, it is possible to protect the ovaries by transporting them out of the RT area through lateral ovary transposition (LOT), as a minimally invasive method, which is performed before the application of RT. A 24-year-old female was diagnosed as having rectal adenocarcinoma in May 2003, and she was scheduled to receive adjuvant 5-fluorouracil-based CT followed by concurrent chemoradiotherapy (CRT). Before the onset of the adjuvant treatments, laparoscopic LOT was performed, and the patient was followed-up appropriately. Although amenorrhea developed during the CRT, the menstrual cycle of the patient resumed without performing any medical treatment eight weeks after the completion of the CRT. In July 2005, the patient became pregnant spontaneously with no local or systemic recurrences of rectal cancer. The present case shows that ovarian functions can be successfully protected in rectal cancer patients receiving RT by laparoscopic LOT, and by modifying the RT fields.

Mechanisms and predictors of high-risk human papillomavirus (HPV) clearance in the uterine cervix.

Abstract: Cervical cancer (CC) and its precursor lesions (CIN) are unique in that we can study the natural history of one disease at two different levels; i) by assessing the clinical lesions, and ii) by analysing the viral events of human papillomavirus (HPV) infections, their prime etiological agent. In this review, we are interested in mechanisms and predictors of clearance of oncogenic HPV infections in the uterine cervix. The outcome (natural history) of CIN has been well established by a large number of prospective cohort studies covering over 25,000 patients, and the figures for regression, persistence and progression are well established. The outcome of HPV infections is far more complex with at least six distinct patterns being demonstrated in long-term cohort studies. There is little doubt that the mechanistic explanation for HPV clearance is by specific immunological reactions, where competent humoral and cell-mediated immune mediators are needed. To understand this process in detail still necessitates a substantial amount of clinical and laboratory research, however. In general, HPV outcomes follow the pattern where a dynamic balance exists between incident infections and virus clearance. Following a rapid accumulation of incident infections after onset of sexual activity (women < 20 years of age), there is a transition of this balance in favour of virus clearance soon after age 25. This explains the constantly declining age-specific prevalence of HPV infections until menopause. Failure to eradicate the virus at postmenopause is not uncommon, however, explaining the deep second peak in HPV prevalence now reported in many different populations. The importance of HPV clearance/non clearance (= persistence) has been recognised recently, and the number of studies addressing these issues has increased substantially during the past few years. The data are now rather unanimous concerning the times and rates (usually expressed per 1,000 women/months at risk, WMR) of HPV clearance. On the other hand, data are still incomplete and in part inconsistent as to the cofactors that regulate these events. A wide variety of variables have been explored as potential co-determinants and/or predictors of HPV clearance, as reviewed in this communication. Until now, all efforts attempting to identify suitable biomarkers as such predictors, have been disappointing, but fortunately, this is a largely unexplored area as yet. Similarly, data on the two extremes of life, i.e., early infancy and postmenopause, are still far too fragmentary to enable creating a comprehensive view, how these viral infections behave in early life, and what makes many women incapable of clearing their virus at postmenopause. Both issues are of utmost importance and have widespread clinical implications; we need to know how and why some infants and children contract HR-HPV infections well before the onset of their sexual activity, to be able to select the proper targets for prophylactic HPV vaccination. Similarly, we need to know why some women over 55 years of age are likely to remain HR-HPV carriers, while the vast majority successfully clears their infection well before the menopausal age. Early detection of cervical cancer precursors among these elderly HR-HPV positive women past the usual age of organised screening remains a major challenge also in the future.

Expression of the CXCR4 and CCR7 chemokine receptors in human endometrial cancer

Abstract: Purpose: The chemokine receptors CXCR4 and CCR7 have been suggested to play an important role in cancer progression but their expression in human endometrial cancer has not been fully characterized. The aim of this study was to investigate CXCR4 and CCR7 expression in endometrial cancers. Methods: We immunohistochemically investigated the expression of CXCR4 and CCR7 protein in 166 endometrial cancers and analyzed the correlation with various observed clinicopathological features, including patient outcome. Fresh tumor specimens were obtained from 55 of the 166 endometrial cancer patients, and the expression levels of the CXCR4 and CCR7 genes were also examined in this subgroup. Results: Our results indicate that CXCR4 and CCR7 transcripts levels are significantly higher in tumors that express the corresponding protein products. CXCR4 and CCR7 protein expression levels were found to be significantly lower in patients with endometrial tumors of a high grade. Consistent with this, the overall survival rates were significantly better in patients exhibiting higher levels of CXCR4 and CCR7 expression. Conclusion: We thus hypothesize that CXCR4 and CCR7 protein levels are suppressed in high-grade endometrial tumors, but that the expression of these receptors per se may not be a crucial role in tumor progression or metastasis in these cancers.

Comparison of human papillomavirus testing and cervical cytology with colposcopic examination and biopsy in cervical cancer screening in a cohort of patients with Sjogren's syndrome.

Abstract: Objective The purpose of this study was to evaluate women with Sjogren Syndrome by using cervical cytology, colposcopic examination and HPV-DNA testing and to compare these findings with those obtained from the control group. Method A total of 100 women, who were referred to Ege University, School of Medicine, Department of Obstetrics and Gynecology for cervical cytological screening between September 2004 and March 2005 and 33 of whom had Sjogren syndrome were included in this study. The patients were informed and subjected to cervical cytology, colposcopic examination and HPV-DNA testing. Colposcopic biopsy and endocervical canal curettage were carried out in cases of suspicious colposcopic examination and cytological findings. The findings obtained from 33 women with Sjogren syndrome and 67 subjects in the control group were compared. Results Normal cervical cytology was detected in five women (5.7%), while suspicious cervical cytology was reported in 62 women (92.5%) in the control group. The prevalence of normal cytology in patients with Sjogren syndrome was 93.9% (n = 31), where 6.1% (n = 2) of the women had suspicious cervical cytology findings. HPV-DNA findings were negative in 66 women (98.5%) in the control group, where the test result of one women (1.5%) was positive. HPV-DNA findings of patients with Sjogren syndrome were positive in one women (3%) and negative in 32 (97%). Colposcopic findings were normal in 63 women (94%) in the control group, where abnormal colposcopic findings were observed in four women (6%). Normal colposcopic findings were observed in 32 women (97%) with Sjogren syndrome, while pathological findings were recorded in one woman (3%). Suspicious cervical cytology, positive findings at colposcopic examination and biopsy and positive HPV-DNA tests were observed together in only one 40-year-old woman who was diagnosed with Sjogren syndrome for a period of four years. Prevalence of dyspareunia and vaginal dryness (atrophic vaginitis) symptoms were observed in Sjogren syndrome and control groups as 36.3% and 22.3%, respectively. Conclusion No significant differences were observed between Sjogren syndrome and the control group who were evaluated by using cervical cytology, colposcopic examination and HPV-DNA tests. A higher prevalence of dyspareunia and vaginal dryness were observed in patients with Sjogren syndrome, yet this difference was not considered as significant with respect to either colposcopic or histopathological findings.

Ovarian clear cell adenocarcinoma producing alpha-fetoprotein: case report.

Abstract: Background Alpha-fetoprotein (AFP) is a useful tumor marker for germ cell tumors of the ovary and is valuable for both diagnosis and follow-up. However, it is very rare for an epithelial ovarian carcinoma to secrete AFP. Case We report a case of a 63-year-old woman with a ovarian clear cell carcinoma with serous component of less than 10%. Both histological components were producing AFP as demonstrated by immunohistochemistry. After surgery and chemotherapy, AFP decreased to normal range. The patient also had elevated CA-125 levels but the tumor was negative for CA-125 which suggested the increased CA-125 might have been due to the associated ascites. Conclusion Ovarian clear cell type carcinomas rarely secrete only AFP and it might be the single marker that could be used in follow-up.

Comparison of symptoms and presentation of women with benign, low malignant potential and invasive ovarian tumors.

Abstract: Objectives: To describe symptoms, delay in presentation and reasons for non-presentation among women diagnosed with benign, low malignant potential and malignant ovarian tumors. Methods: Study participants included 457 women who underwent surgery for an ovarian tumor in Queensland, Australia, between July 1999 and February 2002 (244 with invasive cancer, 62 with low malignant potential tumors, and 151 with benign ovarian tumors). Women were contacted a minimum of three months post-diagnosis. Information concerning symptoms and presentation history was obtained via interview. Results: Overall, only 8% of the women were asymptomatic at the time of their diagnosis. Women with invasive cancer reported a greater number of symptoms (3.1 and 3.6 for Stages I-II and III-IV, respectively) than women with benign or low malignant potential tumors (2.8 and 2.2 respectively; p < 0.0001). Women with invasive disease were more likely to experience weight loss or gain, general malaise, chest/respiratory pain, abdominal swelling and bowel symptoms than women with benign ovarian tumors, however the symptom pattern for early- and late-stage invasive ovarian cancer could not be clearly differentiated. There was no suggestion that women with advanced stage disease had delayed longer before presenting to their doctor. The most common reasons given for not telling their doctor about specific symptoms were the woman's perception that the symptom was not serious enough, it was mild or intermittent, or was related to normal physical changes associated with age or menopause. Conclusions: We found only marginal differences in the symptom patterns of early and advanced stage invasive cancer. Delay in presentation was not associated with more advanced disease suggesting that earlier diagnosis may not increase the proportion of cancers diagnosed at an early stage.

Primary signet-ring cell carcinoma of the uterine cervix with long term follow-up: case report.

Abstract: Background: The uterine cervix represents an exceptional localization of signet-ring cell adenocarcinoma (SRCA). Most commonly, endocervical tumors with such morphology are metastatic from the breast or gastrointestinal tract while primary pure or almost pure tumors are extremely rare. No previous case of primary pure endocervical SRCA with follow-up longer than three years has been found in the literature. Case report: The present report describes such a case of a 46-year-old woman without evidence of recurrence eight years after the diagnosis. The patient was referred to the Gynecology Department for persistent abnormal vaginal bleeding of three months duration. Specular examination and colposcopy revealed a cervical polypoid lesion occupying the posterior lip of the cervix and protruding from the external uterine orifice. A biopsy of the lesion was interpreted by the pathologist as SRCA. An extensive search for an extrapelvic primary cancer was undertaken but revealed no evidence of malignancy. The patient underwent radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node sampling for FIGO Stage 1B1 cervical cancer without any adjuvant chemo- or radiotherapy. The histological diagnosis showed neoplastic signet-ring cells confined in the head of the cervical polyps with minimal stromal infiltration. After surgery the patient underwent close followup including periodic cervicovaginal smears, bimanual vaginal examination, complete laboratory tests, ultrasound and abdominopelvic computed tomography. Conclusions: The prognostic relevance of primitive pure SRCA in the uterine cervix is unclear because of the relatively small number of cases. However the two early deaths out of six reported cases and the absence of follow-up longer than three years for the other affected patients, seem to suggest an aggressive behavior. The present case represents an exceptional long-term survival, probably related to an early diagnosis and a prominent polypoid growth of the neoplasia outside the uterus.

Surgical approach to appendiceal mucocele mimicking an adnexal complex mass: case report.

Abstract: Mucocele of the vermiform appendix is a rare disease of the appendix caused by mucoid substance retention in its lumen, due to obstruction or hyperproduction due to appendiceal retention cysts, mucosal hyperplasia, mucinous cystadenomas and cystadenocarcinomas. Therefore, also appendiceal malignancy can be the underlying cause, making accurate preoperative diagnosis imperative, even if this disease is often asymptomatic and an early diagnosis still remains very difficult on imaging studies. In women, appendiceal mucoceles can sometimes present on clinical and instrumental findings as a right adnexal mass mimicking an ovarian neoplasm. A rare case of appendiceal mucocele in a 36-year-old women with a right-sided painful pelvic mass is presented. The mucocele was misdiagnosed as a cystic complex mass of the right adnexa both clinically and ultrasonographically. Serum levels of CEA and CA19-9 were increased. Explorative laparoscopy was performed revealing an enlarged vermiform appendix with the uterus and adnexa macroscopically normal, and no signs of intraperitoneal metastasis or adnexal torsion. Laparotomic appendectomy followed. Histological examination revealed a mucinous cystadenoma of the vermiform appendix. This clinical entity of appendiceal mucocele should always be considered by gynaecologists as well as gastroenterologists in the differential diagnosis of patients presenting a right-sided adnexal mass on ultrasound in order to choose the best surgical approach.

Loss of OPCML expression and the correlation with CpG island methylation and LOH in ovarian serous carcinoma.

Abstract: Purpose: To detect the expression of OPCML in ovarian serous carcinoma and investigate the correlation with CpG island methylation and LOH of OPCML. Methods: 20 normal tissues, 75 ovarian serous tumors, three cell lines, SKOV-3, CAOV3 and 3AO, were detected in OPCML expression by RT-PCR, CpG island methylation by methylation-sensitive restriction enzyme-PCR, and LOH analysis at four microsatellite marks (D11S4085, D11S1320, D11S874 and D11S969). Results: Loss of OPCML expression in ovarian serous carcinomas was significantly higher than in ovarian adenomas and normal tissues. OPCML expression was detectable in 3AO, but not in SKOV-3 and CAOV3. CpG island methylation was found in 53.4% of the carcinomas, while in none of the adenomas or normal tissues. Meanwhile, CpG island methylation was detectable in SKOV-3 and CAOV3, but not in 3AO. The correlation between CpG island methylation and loss of OPCML expression was found in carcinomas. The LOH rate at D11S4085 in carcinomas was significantly higher than that for adenomas and normal tissues. LOH at D11S4085 was also correlated with loss of OPCML expression. Conclusions: These results indicate that loss of OPCML expression occurs frequently in ovarian serous carcinoma. CpG island methylation and LOH are probably two mechanisms of OPCML inactivation.

Expression and significance of the protein and mRNA of metastasis suppressor gene ME491/CD63 and integrin alpha5 in ovarian cancer tissues.

Abstract: PURPOSE: To investigate the expression and significance of the proteins and mRNA of metastasis suppressor gene Me491/cd63 and integrin alpha5 in ovarian cancer tissues. METHODS: RT-PCR and in situ hybridization were used to detect the expression of the proteins and mRNA of ME491/CD63 and integrin alpha5 in normal ovarian tissues (Group I), ovarian benign tumor tissues (Group II), ovarian borderline tumor tissues (Group III) and ovarian cancer tissues (Group IV), and the correlation between the expression and the age of patient, degree of differentiation, lymphatic metastasis, stage and pathological type was analyzed. RESULTS: There was a significant change in gene expression between the well and moderately differentiated tumors and poorly differentiated tumors. Gene expression in Groups III and IV was significantly weak, and significantly different from that in Group II and the early-stages of Groups III and IV. There was a significant difference in gene expression between each group. CONCLUSION: There is low expression of the proteins and mRNA of ME491/CD63 and integrin alpha5 in ovarian cancer. The lower the pathological differentiation is, the more significant the loss of expression is and the more likely metastasis is.

Significance of hypoxia in uterine cervical cancer. Multicentre study.

Abstract: Purpose: The aim of the study was to evaluate hypoxia markers (VEGF, GLUT-1, and HIF-1alpha) in cervical cancer tissue depending on staging (FIGO) and grading. We also analyzed the adverse effects of radiotherapy according to expression levels of hypoxic markers in the studied tissue. Material and Methods: Expression of hypoxia-inducible factor-la (HIF-1alpha), glucose transporter 1 (GLUT-1) and vascular endothelial growth factor (VEGF, also known as proangiogenic factor) were estimated in biopsy or surgical specimens from 106 patients diagnosed with uterine cervical cancer. Immunohistochemical methods with Eb Vision+ complex using monoclonal antibodies anti-VEGF and anti-HIF- lalpha and polyclonal antibody anti-GLUT-1 were applied. Results and Conclusions: Hypoxia features measured by percentage of cells undergoing reaction with antibodies anti-HIF-lalpha, anti-GLUT-1 and anti-VEGF were similar in all clinical stages; however the biggest hypoxia features were shown in low differentiated cancers G2 and G3. The 5-year survival for FIGO Stage III patients was shorter in cases with a high expression of hypoxic markers. We observed adverse effects in 45.3% of patients, which occurred more often in patients with higher expression of the studied factors. The presence of hypoxic cells is established as one of the most important factors affecting resistance against tumor radiotherapy and patient prognosis.

Management of recurrent cervical cancer. Review of the literature and case report.

Abstract: The purpose of this study is to report the use of a gemcitabine-vinorelbine-cisplatin (GVP) regimen as a successful treatment for a patient with recurrent squamous cervical cancer. The patient was initially diagnosed with a Stage IIb squamous carcinoma of the uterine cervix. A radical hysterectomy with pelvic lymphadenectomy was performed. Adjuvant radiotherapy was given. Eighteen years later, a pelvic recurrence with involvement of the pelvic sidewall was diagnosed and treated with the combination of GVP. A complete clinical and radiological response was achieved and a complete pathological response was confirmed afterwards. Currently, 67 months later, the patient is well and there are no signs of disease. We reviewed the literature concerning the staging and the chemotherapeutical and surgical treatment of recurrent cervical. Based on the recent literature, we conclude that pelvic examination, MRI, PET/CT and laparoscopy are essential in staging recurrent disease, and that laterally extended endopelvic resection (LEER) as well as pre-exenterative chemotherapy are promising novel therapeutic modalities for recurrent cervical cancer with pelvic extension in an irradiated area. In order to make recent data more transparant and practical we designed a classification and flow-chart for the management of recurrent cervical cancer.

Recurrent angiomyofibroblastoma of the vagina: a case report.

Abstract: Angiomyofibroblastoma is a rare tumour of the superficial soft tissue of the pelvis and perineum. It is considered to be a slowly growing benign tumour. In the literature no evidence of recurrence has been reported up to eight years following local excision. We report a recurrent case of this tumour with no evidence of malignant transformation.

Could epithelial ovarian cancer be associated with chlamydial infection

Abstract: Purpose of investigation: Epithelial ovarian cancer (EOC) is the leading cause of death from gynaecological malignancy in the UK. The pathogenesis of this disease is poorly understood. Our hypothesis was that chlamydial infection might play a role in the pathogenesis of EOC. Methods: 122 serum samples of patients undergoing surgery for benign or malignant gynaecological conditions were analysed. There was a total of 41 patients with EOC (33.6%), 27 with benign cystadenomas (22.1%) and 54 with normal ovaries (44.3%). Results: There was a higher incidence of IgA seropositivity and lower incidence of IgG seropositivity in the EOC group compared with the other groups; however, this was not statistically significant. There was no statistical difference in the serum IgM antibodies to chlamydia in the three different groups. Conclusion: Although chronic infection and persistent inflammation may contribute to the pathogenesis of EOC, and chlamydia is a common genital tract pathogen, our study did not find an association between chlamydia and EOC.

Cervical intraepithelial neoplasia: risk factors for persistence and recurrence in adolescents.

Abstract: One of the most common sexually transmitted infections in adolescents is human papillomavirus. These infections can occur in one or multiple areas of the female genitalia but the vulva is usually the initial site of implantation for HPV. We carried out a long-term follow-up study of adolescents to evaluate the incidence of single or multiple lesions in the lower genital tract, the correlation between sexual behaviour and their localisation and behavioural risk factors for persistence and recurrence of HPV lesions and cervical intraepithelial lesion (CIN). We interviewed 268 women aged 12-21 years who had previously had cytology and/or physical examination suspicious for HPV infection. We asked them information about their lifestyle, sexual behaviour, work, personal or family history of genital warts and school attendance. Those who smoked more than five cigarettes a day were considered "smokers". We have no specific data about oral contraception although we know that none of the patients had used oral contraceptives for more than two years. Two hundred and thirty-four young women between the ages of 12 and 21 years were included in the study. The diagnostic schedule for a complete evaluation included exo- and endocervical cytology, colposcopy and directed biopsy. We found that in 126 out of 234 (53.8%) adolescents using contraceptives, only 85 (36.3%) had used a condom. The sites most frequently affected by lesions were the vulva, perianus and perineum (194/234; 82.9%), and the cervix (125/234; 53.4%). Vaginal lesions were detected in only 29/234 patients (12.3%). In 161 patients, sexual habits, age at first intercourse (p = 0.68), frequency of intercourse (p = 0.49) and number of lifetime partners (p = 0.27) as well as age (p = 0.26) played a role in transmission and incidence of HPV infection but not in the location of the lesions. This could be due to coexistent clinical and subclinical multiple infections as well as transmission via intercourse or from other sources, including tampons. HPV infection is detected by abnormal pap test, but the low correlation with colposcopic and histological findings in this study justify the support of other examinations such as colposcopy and punch biopsy for diagnosis. Moreover more attention should be paid to the psychological aspect of diagnoses and treatment of adolescents compared to older women as there was a high rate of patients lost in our study: 75/234 (32.05%) before LASER surgery and 55/159 (34.59%) during follow-up. Only 12-45% of sexually active adolescent girls had obtained Pap smear screening. In our study we found no correlation between treatment failure and cigarette smoking or between the use of oral contraceptives and persistence/recurrence after LASER surgery.

Genetic imbalance and human papillomavirus states in vulvar squamous cell carcinomas.

Abstract: Purpose of investigation: Vulvar squamous cell carcinoma (VSCC) is a disease of significant clinical importance, which arises in the presence or absence of human papillomavirus (HPV). Methods: We used comparative genomic hybridization (CGH) to document non-random chromosomal gains and losses with HPV positive and negative VSCCs. Results: Gains of 3q and 12q were significantly more common in HPV-positive cancers compared to HPV-negative cancers where chromosome 8q was more commonly gained in HPV-negative compared to HPV-positive cancer chromosomes and, 4p and 3p were lost in both categories of VSCCs. Conclusions: The data indicate that one or more oncogenes important in the development and progression of HPV-induced carcinomas are located on 3q and 12q .

Low-grade endometrial stromal sarcoma of the endocervix. Report of a case and review of the literature.

Abstract: Cervical sarcomas are rare entities comprising 0.5% of all primary cervical malignancies. Endometrial stromal sarcoma (ESS) is the least common (< 10%) type of uterine sarcoma. It has traditionally been divided into two categories: low-grade stromal sarcoma (LGSS), which constitutes 50-60% of all ESS, and high-grade stromal sarcoma (HGSS). Low-grade ESS may arise in extrauterine locations, classically described as arising in foci of endometriosis. In our case, a 44-year-old woman presented with a 4-week history of abnormal vaginal secretions and occasional bleeding. Physical examination revealed a soft, hemorrhagic mass on the posterior cervix, approximately 7 x 4 x 3 cm, looking like a degenerated myoma. The patient underwent a radical hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic lymphadenectomy. Histopathological findings, including immunohistochemical study, led to the diagnosis of a LGSS of the endocervix, which was in close relation with endometriotic foci. Our case represents an extrauterine low-grade ESS arising in the endocervix, where a problem in the differential diagnosis was encountered and which was finally treated only with surgery. Adjuvant treatment of ESS is controversial. Generally, low-grade ESS is associated with good prognosis and long overall and disease-free survival.

Use of lysophosphatidic acid in the management of benign and malignant ovarian tumors.

Abstract: Objective: To establish whether LPA determination improves the differentiation of benign from malignant ovarian tumors. Methods: Total LPA and LPA species in the serum were determined using a novel method in 142 patients with ultrasound (US) suspecious ovarian tumors and in 78 healthy women. All women underwent determination of CA125 in the serum, a vaginal US examination and morphology scoring of the tumor. Results: The levels of total LPA and its species in women with ovarian tumors were significantly higher from those in healthy women (p < 0.001). No significant difference was found in the levels of total LPA or any of its species between the women with benign and those with malignant ovarian tumors. Conclusions: Determination of serum LPA would be an appropriate test for ovarian tumor presence, especially in women of reproductive age. The method however does not differentiate benign from malignant ovarian tumors.

Evaluation of anxiety levels during intracavitary brachytherapy applications in women with gynecological malignancies

Abstract: Purpose To evaluate the anxiety levels of women treated for gynecological malignancies using intracavitary brachytherapy. Methods Anxiety levels prior to and after intracavitary brachytherapy application and factors influencing anxiety levels were evaluated. Women were evaluated for quality of life and psychological status before each brachytherapy application using the Hospital Anxiety and Depression Scale (HADS). Scores were grouped as follows: 0-7 = normal, 8-10 = borderline, 11-21 = abnormal. Women were also questioned about other factors which could affect anxiety levels such as marital status, education level, number of pregnancies and prior surgical history. Results Between January 2003 and August 2004, 146 women with a median age of 56 years were evaluated (range: 27-80). Eighty-six women had cervix uteri carcinoma and 63 had endometrial carcinoma. Sixty-seven women were premenopausal and 85 women were postmenopausal. The median pregnancy number was three (range = 0-10). Eighty-nine women had at least three children. Sixty-seven women had had previous operations. One hundred and twenty-five women were married and 24 women were unmarried or widowed. Before treatment, the anxiety scores were scored as normal in 49 (32%), borderline in 41 (28%), and abnormal in 59 (40%). Anxiety levels were lower in 69 women during the last application as compared with the pretreatment levels (p = 0.00). Marital status and pregnancy number showed a significant correlation with anxiety scores (p = 0.04). Age, level of education or having had a previous operation showed no significant correlation with anxiety level. Conclusion These results indicate that intracavitary brachytherapy is associated with anxiety. Women need to be given detailed information before the brachytherapy application to reduce anxiety. Additional studies are needed to determine it.

A rare case of female pelvic mass: angioleiomyoma of the broad ligament.

Abstract: Angioleiomyoma is a benign mesenchymal neoplasm composed of smooth muscle cells and thick-walled vessels. It is usually found in the skin of the lower extremities. Angioleiomyoma is a very rare tumor among the ever-expanding repertoire of growth variants described in benign uterine leiomyoma. More rare is a solitary tumor of the broad ligament. Thus angioleiomyoma of the broad ligament is an extremely rare benign tumor of the female pelvis. In this report a 52-year-old woman with a one-year history of abdominal pain was admitted to our hospital. Gynaecological and ultrasonography exams showed a large mass with increased vascularization in the right adnexal region. The patient underwent total hysterectomy and bilateral salpingo-oophorectomy. The site of the benign mass was the left broad ligament of the uterus. On pathologic examination of the specimen, the tumor was diagnosed as angioleiomyoma. We present a case of angioleiomyoma of the broad ligament because of its extreme rarity and the large size of the tumor.