Four synchronous female genital malignancies: the ovary,cervix, endometrium and fallopian tube

Objective To present a unique case of a 63 year-old woman with coexistent adenocarcinoma of the ovary, endometrium, cervix and fallopian tube. Materials and methods A case report from a tertiary health center. Results A woman presenting with postmenopausal bleeding and abdominal distantion was assessed by endometrial biopsy and explorative surgery. The frozen section of the mass on the right adnex revealed malign mucinous carcinoma of the ovary. As usual, optimal debulking was performed as initial surgical staging procedure of ovarian cancer. The microscopic examination of the right ovary revealed a typical mucinous cystadenocarcinoma. Furthermore, the focal endometrial irregularity at the left uterine cornus turned out to be a well differentiated endometrial carcinoma of the endometrioid type with <1/3 myometrial invasion. The pale infiltrative lesion in the cervix also turned out to be an adenocarcinoma of the endocervical type with deep stromal invasion and areas of diffuse glandular dysplasia and in-situ glandular neoplasia at the periphery. Besides, several sections from the left fallopian tube uncovered diffuse dysplasia in the lining epithelium and a focus of adenocarcinoma with papillary and cribriform pattern. Discussion When compared with patients having metastatic lesions, most synchronous female malignancies are accompanied with early stage and low-grade with a more favorable prognosis. However, there is paucity of data for the exact criterion to distinguish primary tumors from metastatic lesions. In such cases, the validity of immunohistochemical and cloning studies are not clear.     

Acute promyelocytic leukemia: an unusual cause showing prolonged disseminated intravascular coagulation after placental abruption

Background Disseminated intravascular coagulation (DIC) caused by placental abruption usually improves rapidly after prompt delivery and adequate anti-DIC treatment. Case A 30-year-old nulliparous woman suffered from placental abruption at the 25th week of pregnancy, and emergent cesarean section was done immediately. She exhibited DIC, which continued even after termination of the pregnancy and anti-DIC treatment. She also showed neutropenia. We closely observed her, and at the 58th day postpartum, blast cells appeared in the peripheral blood and she was diagnosed with acute promyelocytic leukemia (APL). Induction chemotherapy was done successfully. The close observation after delivery enabled us to make the prompt diagnosis/treatment, leading to the complete remission. Conclusion APL should be added to the list of differential diagnosis when DIC persists even after prompt delivery and appropriate anti-DIC treatment after placental abruption.     

First trimester serum inhibin A in normal pregnant women

Objectives To establish reference ranges for maternal serum inhibin A in normal first trimester pregnant women. Materials and methods This was a cross-sectional study. We measured maternal serum inhibin A in normal pregnant women gestation age between 6⁺⁰ and 14⁺⁶ weeks using the enzyme-linked immunosorbent assay (ELISA) method. Maternal serum inhibin A was analyzed according to gestational ages (GA). Results Serum of 300 pregnancies was analyzed and the outcome demonstrated the median of maternal serum inhibin A according to gestational age. The levels of maternal serum inhibin A during the 6⁰–6⁺⁶ week of gestations are lowest when compared with other gestational age. The levels of maternal serum inhibin A during 9⁰–9⁺⁶ week of gestations are maximal. Maternal serum inhibin A then declined until 14 weeks of gestation. Conclusion Serum inhibin A can be measured during the first trimester of pregnancy by using the recent ELISA technique. Our reference ranges might be useful for further studies, such as prediction of adverse pregnancy outcome in threatened abortion.     

Laparoscopic findings in female genital tuberculosis

OBJECTIVES: To evaluate the laparoscopic findings in genital tuberculosis (TB). METHODS: A total of 85 women of genital TB, who underwent diagnostic laparoscopy for infertility or chronic pelvic pain were enrolled in this retrospective study conducted in our unit at All India Institute of Medical Sciences, New Delhi, India from September 2004 to 2007. RESULTS: The mean age was 28.2 years and the mean parity was 0.24. Most women were from poor socioeconomic status (68.1%). Past history of TB was seen in 29 (34.1%) women with pulmonary TB in 19 (22.35%) women and extrpulmonary in 10 (11.7%) women. Most women presented with infertility (90.6% primary 72.9%; secondary 17.6%) while the rest had chronic pelvic pain (9.4%). The mean duration of infertility was 6.2 years. A total of 49 (57.6%) women had normal menses, while hypomenorrhea, oligomenorrhea, secondary amenorrhea and menorrhagia were seen in 25 (30.1%), 3 (3.5%), 5 (5.9%), and 2 (2.4%) women respectively. Diagnosis of genital TB was made by histopathological evidence of TB granuloma in 16 (18.8%) (Endometrial biopsy in 12.9%, laparoscopy biopsy in 5.9%) women, demonstration of acid fast bacilli (AFB) on microscopy in 2(2.3%), positive AFB culture in 2 (2.3%), positive polymerase chain reaction (PCR) in 55 (64.7%) and laparoscopic findings of genital TB in 40 (47.1%). The various findings on laparoscopy were tubercles on peritoneum (12.9%) or ovary (1.2%), tubovarian masses (7.1%), caseous nodules (5.8%), encysted ascitis in 7.1% women. Various grades of pelvic adhesions were seen in 56(65.8%) women. The various findings on fallopian tubes were normal looking tubes in (7.1%), inability to visualize in 12(14.1%), presence of tubercles on tubes in 3 (3.52%), caseous granuloma in 3 (3.52%), hydrosalpinx in 15 (17.6%) (Right tube 11.7%, left tube 5.9%), pyosalphinx in 3 (3.5%) on right tube and 2 (2.35%) in left tube, beaded tube in 3 (3.5%) on right tube, 4 (4.7%) in left tube with tobacco pouch appearance in 2 (2.35%) women. The right tube was patent in 9 (10.6%) while left tube was patent in 10(11.7%) cases only, while they were either not seen (absent in one case due to previous salphingectomy, inability to see due to adhesion in 14.12%) or blocked at various sites with cornual end being most common in 3 (3.5%) showing multiple block in right tube and 4.7% in left tube. CONCLUSION: There is a significant pelvic morbidity and tubal damage in genital tuberculosis.     

A precarious pregnancy involving a patient with a large placental chorioangioma: a case report

Chorioangiomas are common placental neoplasms that are primarily asymptomatic, but the larger subtypes have a variable presentation and can result in severe pregnancy complications. We report a case of a pregnant patient who presented with a 10 x 12 x 10 cm placental chorioangioma at 32 weeks, despite an unremarkable ultrasound at 28 weeks. Since these more substantial chorioangiomas can induce fetal mortality, close surveillance with perinatology and neonatology consultation is necessary to enhance the probability of a favorable patient prognosis.     

Aggressive angiomyxoma of the vulva: a case report and review of literature

Background Aggressive angiomyxoma (AA) is a rare vulvovaginal mesenchymal neoplasm with a marked tendency to local recurrence but which usually does not metastasize. Case report We describe a case of AA in the left labium majus pudendi in a 47-year-old woman who underwent incomplete surgical excision. Follow-up 2 years later revealed no recurrence. Conclusion In the past, most authors advocated wide excision even if genitourinary and digestive tract resection were necessary. These days, a less radical surgery is recommended, but the significance of hormonal treatment and/or radiation therapy is not clear yet. Further investigation is necessary.     

The nature of intrauterine adhesions following reproductive hysteroscopic surgery as determined by early and late follow-up hysteroscopy: clinical implications

Objective To evaluate the rate and characteristics of postoperative intrauterine adhesions (IUA) that might be formed following hysteroscopic reproductive surgery from both a gross and a histologic perspective as determined by early and late follow-up diagnostic hysteroscopy. Methods Retrospective analysis of 61 women wishing a pregnancy and suffering from a significant intrauterine pathology affecting their reproductive outcome were reviewed. All patients were treated hysteroscopically. Subsequently, they were randomly assigned to perform a follow-up diagnostic hysteroscopy at a variable intervals from their initial surgery. Multiple hysteroscopic-guided biopsies from IUA, when present, were obtained in several cases. Twenty patients were in the early group and had follow-up hysteroscopy performed 2–4 weeks after the initial operation. The late diagnostic group consisted of 41 patients with follow-up hysteroscopy at about 12 months (8–16 months). The two groups were similar to composition. Postoperatively, none of the early diagnostic group underwent hysterosalpingography (HSG) whereas all of the late group performed HSG 4 months following the initial surgery, which showed at least one-third of the cavity free of adhesions. When adhesions were present, no effort was made to lyse them. Results At follow-up hysteroscopy, 25% of both groups had no significant adhesions. Grade I adhesions (thin, filmy) occurred in 60% of the early hysteroscopy patients and in only 12% of the late group (P < 0.05). Grade II adhesions were present in 10% of the early group and in up to 41% in the late group (P < 0.05), whereas Grade III adhesions were present in only 5% of the early hysteroscopy group, but in 22% of the late one (P < 0.05). Correlation between hysteroscopic and histologic findings were good in most of cases in both groups. Follow-up to determine the subsequent reproductive outcome revealed similar conception rates in both groups. Conclusion The IUA that might be formed immediately following hysteroscopic reproductive surgery are histologically different from those appearing a longer time after the original operation. Routine early follow-up hysteroscopy can influence the prognosis resulting from the original surgery.     

Endometrioid carcinoma of the endometrium with choriocarcinomatous differentiation: a case report and review of the literature

OBJECTIVE: An endometrioid adenocarcinoma (EAC) with true trophoblastic differentiation is a rare event with a highly aggressive clinical course. CASE: We report an endometrioid adenocarcinoma of the endometrium in which there was a morphologically conventional-appearing EAC component admixed with multinucleated giant cells and large pleomorphic tumor cells that resembled a choriocarcinoma without an elevated serum level of human chorionic gonadotropin (hCG) in a 42-year-old unmarried woman with a history of abnormal uterine bleeding. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection were performed. Histopathologic study of the specimen showed endometrioid adenocarcinoma extended to the deep myometrium with a focus of hemorrhagic and necrotic tumor composed of multinucleated giant cells, large pleomorphic tumor cells, suggesting choriocarcinomatous differentiation (CD). Immunohistochemical studies demonstrated intense reactivity of tumor cells for human chorionic gonadotropin (hCG) confirming the diagnosis. A complete clinical workup ruled out metastatic spread to the brain, lungs, skeleton, or abdomen. The patient was alive with no evidence of disease 6 months later. CONCLUSION: Although endometrioid adenocarcinoma with choriocarcinomatous differentiation is known to behave in a more aggressive course, this disease may have a good prognosis with a clinically indolent course when it is small, and without elevated serum hCG levels.     

Prepregnancy body mass index and adverse pregnancy outcomes

OBJECTIVE: The aim of this study was to evaluate the association between prepregnancy BMI, and adverse maternal and neonatal outcomes. METHOD: In this retrospective cohort study 916 consecutive singleton gestations were included who gave birth between 1 January 2006 and 31 August 2006 at the Department of Obstetrics and Gynecology, University of Udine, Italy. Statistical analysis was performed using univaried logistic regression and measured by odds ratio. RESULTS: The obese patients had a statistically, significantly increased incidence of Caesarean section (OR = 2.17, p = 0.009). Women with overweight (OR = 2.43, p = 0.002) and obese weight (OR = 4.86, p < 0.0001) were at increased risk for preterm deliveries. The pre-eclampsia and the fetal macrosomia (> or =4,000 g) were increased in obese women (OR = 5.68, p < 0.0001; OR = 2.58, p = 0.033, respectively). CONCLUSION: Maternal prepregnancy obesity is significantly associated with increased risk of Caesarean section, preterm delivery, pre-eclampsia and macrosomia.     

RETRACTED ARTICLE: Perinatal and first year outcomes of spontaneous versus assisted twins: a single center experience

OBJECTIVE: The aim is to compare naturally conceived twins with twins conceived by assisted reproductive techniques (ART) by means of perinatal outcome, behavioural patterns and psychomotor development. MATERIAL AND METHODS: Three hundred and five spontaneous and 119 assisted twins were compared in aspects of behavioural patterns, mental and psychomotor development, as well as maternal and gestational age, foetal presentation, birth weight, sex, Apgar scores, perinatal complications, delivery route, and admission to neonatal intensive care unit (NICU) RESULTS: Although the maternal age was higher in assisted twins, the mean gestational age and birth weight of assisted twins were significantly less than those of spontaneous twins. The assisted twins did not differ from the naturally conceived twins in aspects of presentation, Apgar scores, admission to NICU and perinatal complications. However, caesarean section rate and the delivery rate of male foetuses were significantly higher in assisted twins. During the first year of life, retardation in mental and psychomotor development was more pronounced in assisted twins. Also assisted twins experienced behavioural problems and difficulties in parent-child interactions more frequently. CONCLUSIONS: Although twins born to assisted pregnancies had significantly shorter duration of gestation and thus less birth weight, their perinatal outcome was similar to that of spontaneous twins. The mothers of assisted twins may be keener on getting intensive prenatal care, which might in turn help to diminish any possible maternal and foetal risks. However, assisted twins showed significantly retarded psychomotor and mental development and experienced problems with environmental factors more frequently during their first year.