Adenoid cystic carcinoma of Bartholin's gland: a review of the literature and report of a patient with widespread metastases to the bone

Flam F, Larson B. Adenoid cystic carcinoma of Bartholin's gland: are view of the literature and report of a patient with widespread metastases to the bone. Int J Gynecol Cancer 1997; 7 :458–460.
We report the case of a 41-year-old woman with adenoid cystic carcinoma of Bartholin's gland. Approximately 50 cases of this tumor have been described in the world literature. Local recurrences are common in this disease as well as distant metastases, primarily to the lungs. On the basis of earlier reports this patient was treated with surgery and external radiation. The patient is unique in that she developed widespread bone metastases in the absence of local recurrence.     

Primary treatment of Bartholin''s gland carcinoma with radiation and chemoradiation: a report on ten consecutive cases

We reviewed our experience with primary radiation therapy for Bartholin's gland carcinoma (BGC) as an alternative to traditional surgical treatment. A retrospective study reviewed records from the Cancer Data Registry and Research Patient Data Registry from 1986 to 2002. Charts of ten women identified with BGC were reviewed for demographic information, presenting symptoms, tumor characteristics, treatment modalities, and complications, as well as for recurrence and survival. The incidence of BGC was 2.13% of all invasive vulvar cancer cases at the Massachusetts General Hospital (MGH). Four patients presented with clinical stage I disease, one with stage II, three with stage III, and two with stage IV. The median age at diagnosis was 63.5 years. There were five squamous cell carcinomas, two adenoid cystic carcinomas, two mucinous adenocarcinomas, and one small-cell carcinoma. After a change in treatment policy in 1986 from primary surgery that had often required postoperative radiation therapy, ten consecutive patients were treated with primary radiotherapy or chemoradiation therapy. Treatment included teletherapy combined with a boost to the primary site, regional nodes and/or interstitial brachytherapy. Short-term complications were mild and well tolerated; one patient developed late radiation-associated pelvic fractures. Four tumors recurred with a mean time to recurrence of 31.2 months. The median follow-up was 87.2 months (45-142). Three- and 5-year survivals were 71.5% and 66%, comparable to outcomes after surgery and postoperative radiation therapy. We conclude that primary radiation or chemoradiation therapy offers an effective alternative to surgery in the treatment of BGC with preservation of genital function and low morbidity.     

The problem of accurate initial diagnosis of Bartholin''s gland carcinoma resulting in delayed treatment and aggressive course of the disease

Carcinoma of the Bartholin's gland is a rare lesion accounting for only 5% of all vulvar cancers. Initial diagnosis of Bartholin's gland cancer (BGC) and recurrence after primary radical surgery and adjuvant radiotherapy poses a challenge in the treatment of BGC. This case report presents a particularly aggressive course of BGC. Spontaneous rupture of the femoral artery in the postoperative period was observed. The length of the survival period from the moment of diagnosis amounted to less than 16 months. Aspects of initial diagnosis problem and treatment options in groin recurrence of vulvar carcinoma and vascular complications are discussed.     

Adenoid cystic carcinoma of the Bartholin's gland: the University of Michigan experience

Adenoid cystic carcinoma of the Bartholin's gland has been encountered in 11 patients at the University of Michigan Medical Center since 1936. At the time of presentation the average age was 48.9 years, the lesion size was between 0.5 to 4 cm. The presenting symptoms were pain and/or pruritis associated with a solitary mass. Early in this series, excisional biopsy was used to treat eight patients. The last three patients have been treated with a radical vulvectomy and unilateral or bilateral groin lymph node dissection. Local recurrence has occurred in five patients and distant recurrence in four patients. In spite of the high recurrence rate, 5- and 10-year survival has been high with all seven evaluable patients surviving 5 and 10 years. However, adenoid cystic carcinoma of the vulva is associated with late recurrences and metastases: three patients were dead of disease at 12, 15 and 31 years after initial diagnosis.     

Laparoscopic myomectomy in peri- and post-menopausal women is safe, efficacious and associated with long-term patient satisfaction

Objective

Women in the peri- and post-menopause may ask for uterus-preserving therapy options when presenting with benign uterine disorders such as symptomatic fibroids. Laparoscopic myomectomy (LM) for patients in the peri- and post-menopause as a surgical alternative to hysterectomy is widely considered to be non-standard treatment. The aim of this study was to analyze safety and outcome of LM beyond the reproductive period.

Study design

We evaluated the surgical outcome and patient satisfaction for a total of 451 patients: 85 peri- or post-menopausal women as group A and, for reference, 366 premenopausal women in group B, who received LM from 1998 to 2008 in our department. We analyzed data from our medical records and applied a patient questionnaire in September 2009.

Results

The average number of fibroids removed and size of the leading fibroid were similar in both groups. Time of surgery was different in group A, at 102.8 min, compared to group B, 128.6 min (p < 0.01). Rates of intra- (2.21% overall) and post-operative complications (6.22% overall) were comparable for both groups. Post-surgical hospitalization was shorter in group B (4.4 days) compared to group A (5.0 days) (p < 0.01). Evaluation of the questionnaire showed high satisfaction with the results of LM in both subgroups with a significantly lower number of relapses in group A (3.5%) compared to group B (11.2%).

Conclusion

Laparoscopic myomectomy as a surgical treatment option in the peri- and post-menopause was characterized by a low rate of complications and relapses as well as a high degree of patient satisfaction in our analysis.     

Clinical efficacy of conservative laser therapy for early-stage cervical cancer

The objective of this study was to evaluate the clinical efficacy of conservative laser therapy for early-stage cervical cancer. Seven hundred fifty-two and 271 patients with carcinoma in situ (CIS) and microinvasive squamous cell carcinoma (MIC), respectively, were treated by laser conization with vaporization. One hundred eighty-four patients with preclinical invasive diseases underwent radical surgery without conization. Their postoperative histologic findings and clinical outcomes were evaluated retrospectively. The cone specimens of 1023 cases were reported as showing that 54 had dysplasia, 663 had CIS, 239 had stage Ia1 without lymph vascular space invasion (LVSI), 14 had stage Ia1 with LVSI, 14 had stage Ia2, and 39 had stage Ib1 diseases. Incomplete excision occurred in 4 (7.4%) of 54 dysplasia, 48 (7.2%) of 663 CIS, and 16 (6.7%) of 239 stage Ia1 cases, but failure rates were only 1 (1.9%), 8 (1.2%), and 4 (1.7%), respectively. The other 67 of 1023 cases underwent abdominal operation. Final pathology results were analyzed for 67 and 184 cases with stages Ia1 to Ib1 receiving radical surgery with or without initial laser therapy. Lymph node metastasis was not observed in 154 Ia1 and 30 Ia2 with stromal invasion of under 4 mm in depth regardless of LVSI, but was detected in 2 of 16 Ia2 with stromal invasion of over 4 mm in depth and in 9 of 51 Ib1 cases. CIS and Ia1 disease without LVSI can be treated only by laser therapy. The limit of stromal invasion for conservative laser therapy in stage Ia cancer may be 4 mm in depth regardless of LVSI.     

Clinical studies on photoradiation therapy with hematoporphyrin derivatives (HpD) and argon dye laser

Photoradiation therapy (PRT), in which hematoporphyrin derivatives (HpD) are activated by an argon-dye laser, was performed on superficial or subcutaneous tumors in 4 vulvar carcinoma, 1 vaginal carcinoma, 1 invasive cervical carcinoma and 8 carcinoma in situ (CIS) of the uterine cervix. In PRT with intravenous administration of HpD, PRT obtained complete response (CR) in one vaginal carcinoma with follow up to 6 months. Histological examination, 7 days after PRT, revealed swelling and edema of the tumor, showing degenerated cells with pyknotic nuclei or weakly stained, swollen nuclei. In PRT with local injection or local attachment of HpD, performed on 9 cervical carcinoma, PRT obtained CR in 2 CIS and PR in 7 carcinoma. A side effect with PRT was found in a patient who received intravenous administration of HpD. All patients who received PRT with local administration of HpD were free of side effects. PRT could be used as a primary treatment or upon tumor recurrence following conventional modalities such as surgery, chemotherapy and radiation therapy. In carrying out PRT, selection of patients and improvement of photosensitizing agents and laser equipment were most important.     

Experimental studies on photoradiation therapy by hematoporphyrin derivative (HpD) and argon dye laser

A light sensitive substance, Hematoporphyrin Derivatives (HpD) is known to have an affinity with tumor cells, which are degenerated to necrosis by photoradiation therapy (PRT). Fundamental studies were performed to elucidate the mechanism acting on tumor cells and to evaluate efficiency when applied to gynecological malignancies. The SKG-1 cell line established from uterine cervical cancer was used in this study. No effects on cell growth inhibition (CGI) can be expected by single irradiation. Single HpD has some effects on CGI depending on the HpD concentration and length of treatment time. In PRT, a proportional increase in effects is obtained by extending the irradiation time. More than 90% effectiveness is obtained by irradiation for 5 minutes or more. In a cytomorphological study of the time course changes in cultivated cells subjected to PRT, prominent cytoplasmic changes are observed even immediately after PRT. Advanced changes in nuclei are seen within a few hours after PRT. Electron microscopic findings are mitochondrial swelling and destruction, ER distension, destruction of plasmamembrane and decreased density of nuclei as chromatin disappears. The DNA pattern of the cells 24 hours after PRT showed a shift in the histogram peak to diploid and a remarkable decrease in the number of high ploidy cells above tetraploidy. This indicates early degeneration of DNA after PRT.     

A prospective double-blind randomised controlled trial of intraoperative pelvic instillation with bupivacaine for management of pain following laparoscopy and dye

The aim of this randomised, double-blind, placebo-controlled trial was to evaluate the effectiveness of intraperitoneal instillation of bupivacaine following laparoscopy and dye test. Women received either 15 ml of 0.9% saline (n= 42) or 15 ml of 0.5% bupivacaine (n= 43), which was instilled intraperitoneally. Pain and nausea scores were recorded on a visual analogue scale (VAS). Pain perception was no different in the bupivacaine group compared with the control group with median values of VAS at 2 hours (18, 19; P= 0.8), 6 hours (21, 22; P= 0.5), 12 hours (19, 25; P= 0.8), 24 hours (27, 27; P= 0.9) and 48 hours (21, 13; P= 0.26). Women in the bupivacaine group were less nauseated than controls in the immediate postoperative period (with median VAS scores of 0, 8; P value = 0.03 at 2 hours and 0, 7; P= 0.01 at 6 hours).     

A randomised clinical trial of the effect of low-level laser therapy for perineal pain and healing after episiotomy: A pilot study

Objective

to evaluate the effects of low-level laser therapy for perineal pain and healing after episiotomy.

Design

a double-blind, randomised, controlled clinical trial comparing perineal pain scores and episiotomy healing in women treated with low-level laser therapy (LLLT) and with the simulation of the treatment.

Setting

the study was conducted in the Birth Centre and rooming-in units of Amparo Maternal, a maternity service located in the city of São Paulo, Brazil.

Participants

fifty-two postpartum women who had had mediolateral episiotomies during their first normal delivery were randomly divided into two groups of 26: an experimental group and a control group.

Intervention

in the experimental group, the women were treated with LLLT. Irradiation was applied at three points directly on the episiotomy after the suture and in three postpartum sessions: up to 2 hrs postpartum, between 20 and 24 hrs postpartum and between 40 and 48 hrs postpartum. The LLLT was performed with diode laser, with a wavelength of 660 nm (red light), spot size of 0.04 cm², energy density of 3.8 J/cm², radiant power of 15 mW and 10 s per point, which resulted in an energy of 0.15 J per point and a total energy of 0.45 J per session. The control group participants also underwent three treatment sessions, but without the emission of radiation (simulation group), to assess the possible effects of placebo treatment.

Main outcomes

perineal pain scores, rated on a scale from 0 to 10, were evaluated before and immediately after the irradiation in the three sessions. The healing process was assessed using the REEDA scale (Redness, Edema, Echymosis, Discharge Aproximation) before each laser therapy session and 15 and 20 days after the women's discharge.

Findings

comparing the pain scores before and after the LLLT sessions, the experimental group presented a significant within-group reduction in mean pain scores after the second and third sessions (p=0.003 and p<0.001, respectively), and the control group showed a significant reduction after the first treatment simulation (p=0.043). However, the comparison of the perineal pain scores between the experimental and control groups indicated no statistical difference at any of the evaluated time points. There was no significant difference in perineal healing scores between the groups. All postpartum women approved of the low-level laser therapy.

Conclusions

this pilot study showed that LLLT did not accelerate episiotomy healing. Although there was a reduction in perineal pain mean scores in the experimental group, we cannot conclude that the laser relieved perineal pain. This study led to the suggestion of a new research proposal involving another irradiation protocol to evaluate LLLT's effect on perineal pain relief.     

Concurrent ganirelix and follitropin beta therapy is an effective and safe regimen for ovulation induction in women with polycystic ovary syndrome

OBJECTIVE: To evaluate controlled ovarian stimulation cycles using the GnRH antagonist ganirelix in combination with the recombinant FSH, follitropin-beta, in women with polycystic ovary syndrome (PCOS). DESIGN: Prospective, nonrandomized clinical study. SETTING: Hospital-based infertility practice. PATIENT(S): Twenty women with PCOS planning to undergo ovarian stimulation. INTERVENTION(S): Fasting glucose and insulin levels were used to calculate insulin resistance ratios (FG/I). After pretreatment with oral contraceptives, serum LH levels were determined, and 250 microg ganirelix was administered on cycle day 2. Upon suppression of LH, concurrent ganirelix and follitropin-beta therapy (morning ganirelix and evening follitropin-beta) was started and continued until the day of hCG. MAIN OUTCOME MEASURES: Days of stimulation, dose of follitropin-beta, pregnancy, and ongoing pregnancy were compared based on FG/I ratios. RESULTS: One dose of ganirelix effectively suppressed LH levels in all patients. All patients ovulated as documented by a rise in progesterone. Significant differences were observed between the insulin-resistant and non-insulin-resistant groups for both days of stimulation and dose of follitropin-beta. The overall clinical pregnancy rate was 44.4%, with an ongoing pregnancy rate of 27.8%. CONCLUSIONS: In this preliminary study, we demonstrate the effectiveness of a concurrent ganirelix and follitropin-beta therapy for ovarian stimulation in women with PCOS.     

Diagnosis and management of vulval pain

Vulval pain is a common condition which can cause significant distress to patients. Pain can be from a specific disorder affecting the vulva which presents acutely but becomes a chronic pain if left untreated. If not due to an underlying defined condition, chronic vulval pain is termed Vulvodynia, where pain is classically described as burning in nature. Chronic vulval pain can be challenging for the gynaecologist; correct diagnosis is frequently delayed and treatment is often unsatisfactory. Management relies on a multidisciplinary approach, tailored specifically to the patient.     

Fertilization of bovine oocytes induced solely with combined laser microbeam and optical tweezers

Purpose: Our purpose was to show that fertilization of oocytes can be obtained solely by laser light-mediated manipulation of gametes. Method: A small channel was drilled into the zona pellucida of bovine oocytes using an ultraviolet (UV)-laser microbeam. Highly diluted cattle sperm were not able to fertilize the laser drilled oocytes. Results: Fertilization was achieved only when three to five cattle sperm were trapped with optical tweezers and inserted directly through the laser drilled hole into the perivitelline space. After 20 hr, 3 of 79 (3.8%) oocytes revealed two pronuclei and a sperm tail within their cytoplasm. Cattle sperm are difficult to catch. Therefore, the gametes had to remain for about 20 min in room atmosphere, which might be the reason for the low fertilization results. Conclusions: The results indicate that a combined UV-laser microbeam and optical tweezers trap can be used successfully for noncontact microinsemination procedures.Presented in part at the IXth World Congress on In Vitro Fertilization and Alternate Assisted Reproduction, April 3–7, 1995, Vienna, Austria.     

Use of the pulsed dye laser and ultrasonic lithotriptor for removal of multiple intrahepatic gallstones

Two established urologic modalities used for removal of kidney stones were applied in a complementary manner for percutaneous transhepatic removal of multiple intrahepatic gallstones. A pulsed dye laser was used through a flexible nephroscope to fragment a large impacted stone. A stone basket was used to remove stone fragments and a few small entrapped stones. Subsequently, an ultrasonic lithotriptor carried by a rigid nephroscope was tried and found to be a much more efficient means of removing the remaining small stones.