Giant ovarian tumor – case report and proposal for clinical management

Abstract A case report of a woman with 90kg ovarian tumor is presented. Paracentesis and intravenous alimentation was performed before operation. During the surgery, the ovarian tumor was excised and abdominal cavity packing, followed by slow pressure decreasing, was done. Intravenous together with oral alimentation was continued after the operation. The patient was discharged on the 10th postoperative day, without any complications, in a good overall condition

A method description and feasibility study

A detailed transabdominal and transvaginal ultrasound examination, performed by an expert examiner, could render a similar diagnostic performance to computed tomography for assessing pelvic/abdominal tumor spread disease in women with epithelial ovarian cancer (EOC). This study aimed to describe and assess the feasibility of lung and intercostal upper abdomen ultrasonography as pretreatment imaging of EOC metastases of supradiaphragmatic and subdiaphragmatic areas. A preoperative ultrasound examination of consecutive patients suspected of having EOC was prospectively performed using transvaginal, transabdominal, and intercostal lung and upper abdomen ultrasonography. A surgical-pathological examination was the reference standard to ultrasonography. Among 77 patients with histologically proven EOC, supradiaphragmatic disease was detected in 13 cases: pleural effusions on the right (n = 12) and left (n = 8) sides, nodular lesions on diaphragmatic pleura (n = 9), focal lesion in lung parenchyma (n = 1), and enlarged cardiophrenic lymph nodes (n = 1). Performance (described with area under the curve) of combined transabdominal and intercostal upper abdomen ultrasonography for subdiaphragmatic areas (n = 77) included the right and left diaphragm peritoneum (0.754 and 0.575 respectively), spleen hilum (0.924), hepatic hilum (0.701), and liver and spleen parenchyma (0.993 and 1.0 respectively). It was not possible to evaluate the performance of lung ultrasonography for supradiaphragmatic disease because only some patients had this region surgically explored. Preoperative lung and intercostal upper abdomen ultrasonography performed in patients with EOC can add valuable information for supradiaphragmatic and subdiaphragmatic regions. A reliable reference standard to test method performance is an area of future research. A multidisciplinary approach to ovarian cancer utilizing lung ultrasonography may assist in clinical decision-making.publishersversionpublishe

Zapalenie wyrostka robaczkowego i choroby pęcherzyka żółciowego jako stany ostre wymagające pilnej interwencji chirurgicznej u kobiet w ciąży

Appendicitis (APP) and gall bladder diseases (GBD) are the most frequent non-obstetric indications for urgent surgery among pregnant women. The aim was to present the diagnosis, treatment and potential complications of APP and symptomatic GBD. We searched the literature for APP and GBD during pregnancy and presented the results in the form of a review article. APP symptoms among pregnant women are comparable to these in the general population. Typical clinical symptoms are present in 50-75% of cases. Laboratory tests are useful for a differential diagnosis. The imaging of choice is an ultrasonography scan, but magnetic resonance is of the highest accuracy. The final diagnosis is difficult. When the surgery is delayed, the risk of appendix perforation increases and thus complications are more frequent. GBD symptoms and signs are comparable to those in the general population. The best imaging is an ultrasonography scan, and laboratory tests are important in a jaundice differential diagnosis. In cases with symptomatic GBD, a delay in surgery is associated with an increased risk of complications (pancreatitis, abortion, intrauterine death). The treatment method of choice for APP and symptomatic GBD is surgery, both laparotomy and laparoscopy (preferred), which are considered relatively safe, though laparoscopy compared to laparotomy for APP can be associated with a higher risk of abortion. Untreated or delayed APP and symptomatic GBD treatment during pregnancy increases the risk of complications, both for the woman and the fetus. Diagnosis is difficult and should be based on a multidisciplinary approach to the patient. Surgery by laparotomy or laparoscopy is relatively safe.Zapalenie wyrostka robaczkowego (APP) i choroby pęcherzyka żółciowego (GBD) są najczęstszymi, nie położniczymi wskazaniami do pilnej operacji chirurgicznej u ciężarnych. Celem pracy było przedstawienie diagnostyki, leczenia i potencjalnych powikłań APP i objawowych GBD. Dokonano przeglądu piśmiennictwa na temat APP i GBD u ciężarnych i opisano w formie pracy poglądowej. Wywiad u chorych ciężarnych z APP jest podobny jak w populacji ogólnej, zaś typowe objawy przedmiotowe są stwierdzane u 50-75%. Badania laboratoryjne pozwalają wykluczyć inne jednostki chorobowe. Metodą diagnostyki obrazowej jest ultrasonografia, jednak rezonans magnetyczny ma największą dokładność. Rozpoznanie jest trudne i opiera się na łącznej analizie wyników wszystkich badań. Odraczanie operacji powoduje wzrost ryzyka perforacji wyrostka robaczkowego, w konsekwencji częstsze niepowodzenia położnicze, oraz powikłania dla chorej. Wywiad i badanie kliniczne u ciężarnych z objawowymi GBD są podobne jak w populacji ogólnej. Metodą obrazowania jest ultrasonografia. Ważne są badania laboratoryjne, szczególnie w różnicowaniu żółtaczek. Odraczanie leczenia operacyjnego objawowych GBD wiąże się ze zwiększonym ryzykiem powikłań u ciężarnej (zapalenie trzustki) oraz niepowodzeń położniczych (poronienia, zgon wewnątrzmaciczny płodu). Postępowaniem z wyboru w przypadkach APP i objawowych GBD jest leczenie chirurgiczne przez laparotomię lub laparoskopię, z których ta druga jest metodą zalecaną. Obie metody są relatywnie bezpieczne, choć laparoskopia w porównaniu z laparotomią w przypadku APP może zwiększać ryzyko poronień

Niedrożność przewodu pokarmowego u kobiet ciężarnych

This is a review of literature concerning intestinal obstruction in pregnant women. Approximately 50-90% and 30% of pregnant women, respectively, suffer from nausea and vomiting, mostly during the first trimester. There is also increased risk of constipation. During the perioperative period, the administration of tocolytics should be considered only in women showing symptoms of a threatening premature delivery. Intensive hydration should be ordered to sustain uterine blood flow. The incidence of intestinal obstruction during pregnancy is estimated at 1:1500-1:66431 pregnancies and is diagnosed in II and III trimester in most cases. However, it can also occur in the I trimester (6%) or puerperium. Symptoms of intestinal obstruction in pregnancy include: abdominal pains (98%), vomiting (82%), constipation (30%). Abdominal tenderness on palpation is found in 71% and abnormal peristalsis in 55% of cases. The most common imaging examination in the diagnosis of intestinal obstruction is the abdominal X-ray. However, ionizing radiation may have a harmful effect on the fetus, especially during the first trimester. X-ray is positive for intestinal obstruction in 82% of pregnant women. Ultrasonography and magnetic resonance imaging are considered safe and applicable during pregnancy. Intestinal obstruction in pregnant women is mostly caused by: adhesions (54.6%), intestinal torsion (25%), colorectal carcinoma (3.7%), hernia (1.4%), appendicitis (0.5%) and others (10%). Adhesive obstruction occurs more frequently in advanced pregnancy (6% - I trimester, 28% - II trimester, 45% - III trimester, 21% - puerperium). Treatment should begin with conservative procedures. Surgical treatment may be necessary in cases where the pain turns from recurrent into continuous, with tachycardia, pyrexia and a positive Blumberg sign. If symptoms of fetal anoxia are observed, a C-section should be carried out before surgical intervention. The extent of surgical intervention depends on the intraoperative evaluation. Intestinal torsion during pregnancy mostly occurs in the sigmoid colon and cecum. Small bowel torsion secondary to adhesions is diagnosed in 42% of pregnant women with intestinal obstruction. The risk of intestinal torsion is higher in the 16-20 and 32-36 weeks of pregnancy and during puerperium. Intestinal torsion results in vessel occlusion which induces more severe symptoms and makes urgent surgical intervention necessary. The overall prognosis is poor – during II and III trimester the fetal mortality rate reaches 36% and 64%, respectively, while the risk of maternal death is 6%. Acute intestinal pseudoobstruction can be diagnosed during puerperium, especially following a C-section. Diagnosis is made on the basis of radiological confirmation of colon distension at the cecum as >9cm, lack of air in the sigmoid colon and rectum, exclusion of mechanical obstruction. In most cases, the treatment is based on easing intestine gas evacuation and administering neostigmine. The authors point out the need for multi-specialty cooperation in the diagnostic-therapeutic process of pregnant women suspected with intestinal obstruction, since any delay in making a correct diagnosis increases the risk of severe complications, both for the woman and the fetus.Niedrożność przewodu pokarmowego u kobiet ciężarnych obserwuje się rzadko, jednakże opóźnienie w rozpoznaniu tego stanu zwiększa ryzyko istotnych powikłań, tak dla kobiety, jak i dla płodu. W pracy dokonano przeglądu aktualnych danych z piśmiennictwa na temat niedrożności przewodu pokarmowego u kobiet w ciąży. Odnosząc się do ogólnie znanych przemian fizjologicznych u ciężarnych właściwych dla poszczególnych okresów ciąży przedstawiono szczegóły diagnostyki i leczenia stanu niedrożności, w tym podstawy postępowania okołooperacyjnego. Wskazano na obowiązek wielospecjalistycznej współpracy w procesie diagnostyczno-leczniczym ciężarnej podejrzanej o niedrożność przewodu pokarmowego

Mutational analysis of BRCA1/2 in a group of 134 consecutive ovarian cancer patients. Novel and recurrent BRCA1/2 alterations detected by next generation sequencing

The importance of proper mutational analysis of BRCA1/2 in individuals at risk for hereditary breast and ovarian cancer syndrome is widely accepted. Standard genetic screening includes targeted analysis of recurrent, population-specific mutations. The purpose of the study was to establish the frequency of germline BRCA1/2 mutations in a group of 134 unrelated patients with primary ovarian cancer. Next generation sequencing analysis revealed a presence of 20 (14.9 %) mutations, where 65 % (n = 13) were recurrent BRCA1 alterations included in the standard diagnostic panel in northern Poland. However, the remaining seven BRCA1/2 mutations (35 %) would be missed by the standard approach and were detected in unique patients. A substantial proportion (n = 5/12; 41 %) of mutation-positive individuals with complete family history reported no incidence of breast or ovarian cancer in their relatives. This observation, together with the raising perspectives for personalized therapy targeting BRCA1/2 signaling pathways indicates the necessity of comprehensive genetic screening in all ovarian cancer patients. However, due to the limited sensitivity of the standard genetic screening presented in this study (65 %) an application of next generation sequencing in molecular diagnostics of BRCA1/2 genes should be considered

Recommendations of the Polish Society of Gynaecologists and Obstetricians, Polish Paediatric Society, Polish Society of Family Medicine, Polish Society of Vaccinology, Polish Society of Oncological Gynaecology and Polish Society of Colposcopy and Pathophysiology of the Uterine Cervix on prophylactic vaccinations against infections with human papillomaviruses in Poland

Several hundred million people are infected with genital genotypes of the human papillomavirus (HPV) annually in the world. The infections transmitted mainly through sexual routes are usually asymptomatic, but can lead to the development of cervical, vulvar, vaginal, anal, penile cancers, some head and neck cancers and genital warts (condylomas). The fraction HPV-related cancers range from nearly 100% in the case of cervical cancer to several/over a dozen percent in the case of other cancers and diseases. There are no effective drugs against HPV, but prophylactic HPV vaccines are available free of charge in immunization programmes in many countries around the world. In Poland, HPV vaccinations have so far been executed out on the pocket or in free-of-charge, local-governmental prevention programs, but the vaccination coverage of the target population does not exceed 10%. From November 2021, one of the vaccines is available with a 50% reimbursement, work is underway to reimburse the next ones, and the National Oncology Strategy assumes the implementation of the HPV immunization programmes and vaccination of 60% of the teen population by 2028. Three prophylactic HPV vaccines are registered. All of them are safe and their effectiveness in the prevention of diseases caused by vaccine genotypes reaches almost 100%, provided that full post-vaccination immunity is obtained before the contact with the virus. Girls aged 11-13 are the priority target cohort for HPV vaccination in Poland. The implementation of routine, free-of-charge HPV immunization in the Preventive Immunization Program (PIP) for all adolescents should be pursued. Persons over the age of 13 may also benefit from HPV vaccination and should be vaccinated according to product specifications. In addition to free access under the PIP, the key element for the success of the implementation of HPV vaccinations in Poland will be the education of medical personnel and parents of adolescents to be vaccinated

Potential Targets' Analysis Reveals Dual PI3K/mTOR Pathway Inhibition as a Promising Therapeutic Strategy for Uterine Leiomyosarcomas-an ENITEC Group Initiative

Purpose: Uterine sarcomas are rare and heterogeneous tumors characterized by an aggressive clinical behavior. Their high rates of recurrence and mortality point to the urgent need for novel targeted therapies and alternative treatment strategies. However, no molecular prognostic or predictive biomarkers are available so far to guide choice and modality of treatment. Experimental Design: We investigated the expression of several druggable targets (phospho-S6(S240) ribosomal protein, PTEN, PDGFR-alpha, ERBB2, and EGFR) in a large cohort of human uterine sarcoma samples (288), including leiomyosarcomas, low-grade and high-grade endometrial stromal sarcomas, undifferentiated uterine sarcomas, and adenosarcomas, together with 15 smooth muscle tumors of uncertain malignant potential (STUMP), 52 benign uterine stromal tumors, and 41 normal uterine tissues. The potential therapeutic value of the most promising target, p-S6(S240), was tested in patient-derived xenograft (PDX) leiomyosarcoma models. Results: In uterine sarcomas and STUMPs, S6S240 phosphorylation (reflecting mTOR pathway activation) was associated with higher grade (P = 0.001) and recurrence (P = 0.019), as shown by logistic regression. In addition, p-S6(S240) correlated with shorter progression-free survival (P = 0.034). Treatment with a dual PI3K/mTOR inhibitor significantly reduced tumor growth in 4 of 5 leiomyosarcoma PDX models (with tumor shrinkage in 2 models). Remarkably, the 4 responding models showed basal p-S6(S240) expression, whereas the nonresponding model was scored as negative, suggesting a role for p-S6(S240) in response prediction to PI3K/mTOR inhibition. Conclusions: Dual PI3K/mTOR inhibition represents an effective therapeutic strategy in uterine leiomyosarcoma, and p-S6(S240) expression is a potential predictive biomarker for response to treatment. (C)2017 AACR.Peer reviewe

Relevance of endocervical cells in Pap smears conducted for prevention of clear cell carcinoma of the cervix – two case presentations

A cervical smear is a test aimed at detecting precancerous lesions and cancer at an early clinical stage. The introduction of a Pap smear as a screening test has reduced the number of newly diagnosed squamous cell carcinomas of the cervix by 42% in 20 years. At the same time, an increase in the incidence of adenocarcinomas originating from glandular, endocervical cells, has been observed. The Bethesda system, which documents the presence or absence of glandular cells of the cervix and defines their pathologies, is currently recommended for evaluation of cervical cytology. Most of the prevention programs recommend to screen every 2–3 years. We report a case of two women with cervical clear cell adenocarcinoma – a rare subtype (5–7%) of adenocarcinomas, diagnosed in stage FIGO IB2 that developed despite regular (every year) cytological screening. The last Pap smears were performed 12 and 13 months before the diagnosis and no abnormalities were found. The results were normal and no endocervical cells were found in the smear. The radical surgical treatment was implemented, followed by an adjuvant therapy. In post-surgical tissues, HPV-18 DNA was detected in both patients. During 24 and 19 months of follow-up, no recurrences were noticed.Cytologia szyjki macicy jest badaniem ukierunkowanym na wykrywanie zmian przedrakowych lub nowotworów we wczesnym stopniu zaawansowania klinicznego. Wprowadzenie cytologii jako badania przesiewowego spowodowało zmniejszenie w ciągu 20 lat liczby nowo rozpoznawanych raków płaskonabłonkowych szyjki macicy o 42%. Jednocześnie odnotowano wzrost częstości występowania gruczolakoraków, wywodzących się z gruczołowych komórek endocerwikalnych. Obecnie do oceny cytologii zaleca się wykorzystanie systemu Bethesda, który między innymi dokumentuje obecność lub brak komórek gruczołowych szyjki macicy oraz definiuje ich patologię. Większość programów profilaktycznych rekomenduje wykonywanie badań przesiewowych co 2–3 lata. Przedstawiono opis dwóch pacjentek z jasnokomórkowymi gruczolakorakami szyjki macicy – rzadkim (około 5–7%) podtypem gruczolakoraków, rozpoznanymi w stopniu zaawansowania IB2 według klasyfikacji FIGO, mimo regularnie, corocznie prowadzonej profilaktyki cytologicznej. Ostatnie badania wykonano na 12 i 13 miesięcy przed rozpoznaniem. Wyniki były prawidłowe, ale nie stwierdzono obecności komórek endocerwikalnych w rozmazie. Chore poddano radykalnemu leczeniu operacyjnemu oraz leczeniu uzupełniającemu. W materiale pooperacyjnym dokonano oznaczenia DNA HPV i wykazano obecność HPV-18. Obie pacjentki pozostają pod obserwacją. W ciągu 24 i 19 miesięcy obserwacji nie wystąpiła u nich wznowa choroby

Ultrasound-Guided Trans-Uterine Cavity Core Needle Biopsy of Uterine Myometrial Tumors to Differentiate Sarcoma from a Benign Lesion—Description of the Method and Review of the Literature

Uterine sarcomas are rare, aggressive tumors with poor prognosis that can be further negatively affected by inadequate surgical approaches such as morcellation. There are no clinical and radiologic criteria for differentiating leiomyoma from malignant uterine tumors. However, some ultrasonography and magnetic resonance imaging findings may be informative. We present a technique of ultrasound-guided trans-uterine cavity (UG-TUC) core needle biopsy for uterine lesions. As the procedure is an in-organ biopsy, there is no risk of needle canal contamination. The technique also enables the biopsy of lesions inaccessible by the transvaginal tru-cut biopsy. The core needle of the automatic biopsy system is inserted via the cervical canal into the uterine cavity and is directed and activated at the myometrial lesion under ultrasound control. The standard local treatment of localized uterine sarcomas is en bloc total hysterectomy; for fibroids, there are multiple options including conservative management or tumorectomy and tumor morcellation using minimally invasive techniques. Fragmentation of the sarcoma significantly worsens oncologic outcomes and should therefore be avoided. The UG-TUC core needle biopsy of uterine lesions can complement imaging to obtain sufficient material for histologic and molecular analyses of suspected or undetermined lesions, thus facilitating treatment planning and decreasing the risk of unsuspected sarcomas

Accuracy of Ultrasonography and Magnetic Resonance Imaging for Preoperative Staging of Cervical Cancer—Analysis of Patients from the Prospective Study on Total Mesometrial Resection

We aimed to evaluate the accuracy of ultrasonography with gynecologic examination performed by a gynecological oncologist and magnetic resonance imaging (MRI) interpreted by a radiologist for the local and regional staging of patients with early-stage cervical cancer. The study was a single-site sub-analysis of the multi-institutional prospective, observational Total Mesometrial Resection (TMMR) Register Study, which included all consecutive study patients from Gdynia Oncology Center. Imaging results were compared with pathology findings. A total of 58 consecutive patients were enrolled, and 50 underwent both ultrasonography and MRI. The accuracy of tumor detection and measurement errors was comparable across ultrasonography and MRI. There were no significant differences between ultrasonography and MRI in the accuracy of detecting parametrial involvement (92%, confidence interval (CI) 84–100% vs. 76%, CI 64–88%, p = 0.3), uterine corpus infiltration (94%, CI 87–100% vs. 86%, CI 76–96%, p = 0.3), and vaginal fornix involvement (96%, CI 91–100% vs. 76%, CI 64–88%, p = 0.3). The importance of uterine corpus involvement for the first-line lymph node metastases was presented in few cases. The accuracy of ultrasonography was higher than MRI for correctly predicting tumor stage: International Federation of Gynecology and Obstetrics (FIGO)–2018: 69%, CI 57–81% vs. 42%, CI 28–56%, p = 0.002, T (from TNM system): 79%, CI 69–90% vs. 52%, CI 38–66%, p = 0.0005, and ontogenetic tumor staging: 88%, CI 80–96% vs. 70%, CI 57–83%, p = 0.005. For patients with cervical cancer who are eligible for TMMR and therapeutic lymphadenectomy, the accuracy of ultrasonography performed by gynecological oncologists is not inferior to that of MRI interpreted by a radiologist for assessing specific local parameters, and is more accurate for local staging of the disease and is thus more clinically useful for planning adequate surgical treatment