Alcohol Sclerosing Ovarian Cystic Lesions, 20 Years Experience

The purpose of the study is to present technique of punction and conservative treatment of cystic ovarian lesions. The following criteria were included: 1) Cyst should be unilocular, sonolucent, with a smooth inner wall of capsule, without septa and without neovasculariation on transvaginal color and power Doppler. 2) Serum CA-125 levels must be lower than 35 U/mL. The capsule of the cyst was punctured with a 18 gauge needle under the control of 5 MHz transvaginal probe. Cyst fluid was sent for cytologic examination. After complete emptyng of the cyst, we injected sterile 95% ethanol in the 50–75% of the evacuated liquor amount. The alcohol remain in the cyst from 5 to 20 minutes and was then aspirated completely. We punctured cysts in 366 patients aged from 18 to 65 years, volume of cyst being between 40 and 300 mL. Patients were monitored for 24 hours and follow-up examinations were 3, 6 and 12 months after the procedure. Three cysts were ruptured (0.8%) and alcohol split in the Douglas cavity. Intensive pelvic pain had 8.1% and relapse appeared in 8.2% of the patients. Technique of punction is simple and easily performed. Method of treating by 95% alcohol has demonstrated good results. Relapse we treated by laparoscopy or laparotomy

Estimating Clinical Outcome of HPV Induced Cervical Lesions by Combination of Capsid Protein L1 and p16INK4a Protein Detection

The aim of this study was to investigate whether is possible to predict clinical outcome of cervical lesion by immunoassaying performed on cervical smears. During the two year study period the cervical smears of 81 patients were collected. All patients were tested for human papillomavirus (HPV) infections using Amplycor HPV test. Sixty-six of them were tested as positive for high risk types (hrHPV) and squamous intraepithelial lesion, and in those patients repeated cervical smears were taken every six months. The rest were hrHPV negative patients with normal smears which were used as a negative control in immunoassays with HPV L1 and p16INK4a antibodies. The results of p16INK4a staining in 66 hrHPV positive patients showed impairment of the cervical lesion in 22 (33.3%) and unchanged cytological finding in 21 (31.9%) p16INK4a positive patients, respectively, while improving of cytological finding was seen only in three (4.5%) p16INK4a positive patients. On the contrary, impairment of cytological finding was not seen in p16INK4a negative patients, while in 17 out of 20 patients from that group improving or normalisation of cytological finding were detected (p<0.01). Correlation between L1/p16 pattern and cytological finding showed that only in L1–/p16+ cervical lesions was detected impairment of cytological finding during the study period. In L1+/p16+ group the cytological finding was the same during the follow up in all 11 patients, while in L1+/p16– group in most patients (9/11) downgrading or normalisation of Pap test were detected. The usage of p16 and HPV L1 markers can be useful in estimation of biologic potentiality and clinical outcome of cervical lesions

Metastasis of endometrial cancer in ovary or synchronous primary cancers of endometrium and ovary – case report

Primarni karcinom endometrija najčešća je maligna neoplazma ženskoga spolnog sustava. Prvotni simptomi, kada se i dijagnosticira u početnom stadiju bolesti, jesu nepravilna i/ili produljena krvarenja u premenopauzi ili krvarenja u postmenopauzi. Ostali su simptomi boli u zdjelici ili abdomenu ili abnormalni Papanicolaouov test. Bolesnice su najčešće u postmenopauzalnom razdoblju, ali ni žene generativne dobi nisu isključene. Radovi su pokazali da žene generativne dobi s dijagnosticiranim karcinomom endometrija imaju povišen rizik i od istodobne bolesti karcinoma jajnika i nasljednoga nepolipoznog karcinoma kolona. Upravo je entitet istodobnoga primarnog karcinoma endometrija i jajnika velika dijagnostička zamka jer ne postoje jedinstveni histološki algoritam ni kirurški postupnik, a potrebno ga je odvojiti od primarnog karcinoma jajnika i metastatskog širenja karcinoma endometrija u jajnik radi povoljnije prognoze i mogućnosti poštednijega kirurškog zahvata u mlađih bolesnica te očuvanja fertiliteta. U radu prikazujemo bolesnicu u dobi od 49 godina, s anamnestičkim podacima o obilnijim krvarenjima i postojanju ciste na jajniku, kod koje se nakon intenzivnih i naglih boli te zbog sumnje na rupturu ciste pristupilo hitnom laparoskopskom zahvatu. Zbog intraoperativnoga citološkog nalaza sa sumnjom na maligni proces i pozitivnoga patohistološkog nalaza operacija je konvertirana u laparotomiju. Detaljnom patohistološkom analizom uz imunohistokemijsku dopunu dijagnosticirana je rasadnica (metastaza) endometrioidnog adenokarcinoma endometrija.Primary endometrial cancer is the most common malignant neoplasm of the female reproductive system. It is most commonly detected in the first stage of the disease. The most frequent initial symptoms are irregular or prolonged bleeding in premenopausal or bleeding in postmenopausal women. Other symptoms are pain in the pelvis or abdomen, or abnormal Pap smear. Patients are most often in postmenopausal period of life but women in generative age are not excluded. Different researches have shown that women of generative age with endometrial cancer have an increased risk of the synchronous disease of ovarian cancer and hereditary non-polypoid colon cancer. This is exactly corroborated by the fact that primary cancer in the reproductive system of women may occur at the same time, especially in endometrial cancer and in ovarian cancer. The entity of the synchronous primary cancer of endometrium and ovary is a large diagnostic trap because there is no unique histological algorithm or unique attitude for surgical procedure. However,, it is necessary to separate this entity from primary ovarian cancer and metastatic endometrial cancer in the ovary because of its better prognosis and possibility for less aggressive surgery in younger patients with preservation of fertility. We present a 49-year-old patient with history data on abundant bleeding and the existence of ovarian cyst. After intense and severe pain, and because of the suspicion of the rupture of the cyst, the emergency laparoscopic surgery was done. Intraoperative cytological analysis raised doubt about malignant process. Intraoperative histological finding was positive for endometrioid malignant process. Operation was converted to laparotomy. Detailed histopathological analysis, complemented with immunohistochemical procedure, diagnosed metastasis of endometrioid adenocarcinoma of endometrium

Cytological diagnosis of endometrial disorders – cases reviews

Kada se govori o citološkoj dijagnostici endometrijskih poremećaja, tada razmatramo mogućnosti vizualizacije stanja i promjena u tijelu maternice direktnom metodom uzorkovanja materništa četkicom (uterobrush). Uzorkovanje se izvodi ambulantno, bez anestezijskih postupaka, s manjom nelagodom za pacijentice, a citološki nalazi s reprezentativnim uzorcima omogućuju usmjeravanje na daljnju dijagnostiku, praćenje bolesnica s endometrijskim promjenama te izdvajanje onih kod kojih su potrebne daljnja obrada i dijagnostika. Cilj je ovog rada pokazati vrijednost metode materničnog četkanja i citološke dijagnostike prikazima triju bolesnica: jedne s atipičnom hiperplazijom endometrija pod suprimirajućom terapijom gestagenom, druge u koje je dijagnosticiran pločasti karcinom i treće s granulomatoznom upalom u aspiratu materništa. Želimo pokazati da se metodom materničnog četkanja dobivaju zadovoljavajući uzorci na kojima se mogu detektirati patološke promjene materništa, da je ta metoda pogodna za neinvazivno praćenje pacijentica te da bi trebala zauzeti odgovarajuće mjesto u postupniku obrade bolesnica s endometrijskim poremećajima.When we talk about cytological diagnosis of endometrial disorders then we also consider the possibility of visualization conditions and pathological changes in the corpus of uterus by direct sampling with uterobrush. It can be performed without hospitalization and anaesthetic procedures with less discomfort for the patients. The representative samples provide cytological reports with the guidance for further diagnostic procedure. Cytological findings of uterobrush samples may indicate which patients have endometrial changes and require further treatment. The aim of this report is to show the benefit of using the uterobrush and cytological analysis through the reviews of different cases, for example: finding atypia in patient with the endometrial hyperplasia under the gestagen therapy or diagnosis of squamous carcinoma or granulomatous inflammation in the endometrial samples. We want to demonstrate that satisfactory direct endometrial sampling can detect endometrial pathological changes and are suitable for noninvasive monitoring of the symptomatic patients, so it should take place in the algorithm for patients with endometrial disorders

Vulvar Paget’s Disease – A Case Report

Vulvar Morbus Paget (MP) represents a rare intraepithelial adenocarcinoma. It accounts for less than 1% of all vulvar neoplasia and usually appears in postmenopausal women. Histologically it is analogous to Paget’s disease of the breast. The most common clinical symptom is pruritus. The lesion appears as an erythematous or as an eczematous lesion with islands of hyperkeratosis. Occasionally, single anaplastic Paget’s cells can be found on the vulvar smears which make cytological diagnosis of the disease possible. However, the disease can be diagnosed only by biopsy. We present a case of 49-year old woman with vulvar symptoms of pruritus, who had liver and kidney transplantation two years ago. During the standard gynecological examination the vulvar smear was taken for cytological evaluation. The smear was scanty, with inflammatory background, overloaded with squamae. There were two types of cells: dysplastic squamous cells from lower layer of the epithelium and the single, anaplastic cells with a high nuclear:cytoplasmic ratio who possessed eccentric, large nucleus. Nucleoli were rare. Cytoplasm varied from pale and delicate to densely basophilic. Accordingly, cytological diagnosis vulvar intraepithelial neoplasia (VIN III) with differential diagnosis of vulvar Paget’s disease was made. The pathological verification supported the diagnosis of MP and an immunohistochemistry panel confirmed type III of Paget’s disease and an evaluation of bladder was suggested

HISTORY OF GYNECOLOGIC CYTOLOGY IN CROATIA

Prvi laboratorij za ginekološku citologiju u Hrvatskoj osnovan je 1953. godine u današnjoj Klinici za ženske bolesti i porode Kliničkog bolničkog centra (KBC) Zagreb. Prvi voditelj bio je ginekolog Eduard Baršić, a od 1959. liječnice koje se bave isključivo citologijom i postaju specijalisti kliničke citologije. Prva je Jasna Ivić, koja je na čelu laboratorija do 1990. godine i najzaslužnija je za visoki stupanj razvijenosti ginekološke citologije u Hrvatskoj. Godine 1984. laboratorij prerasta u Zavod za ginekološku citologiju. Pola stoljeća Zavod je, kao vodeći laboratorij u nas, u suradnji s drugim uglednim institucijama i stručnjacima, posebice s Odsjekom za citologiju i kliničku genetiku Klinike za ženske bolesti i porode KB »Merkur« iz Zagreba, inducirao i realizirao razvoj ginekološke citologije u stručnom, znanstvenom i nastavnom području i promicao ugled hrvatske ginekološke citologije u svijetu. Početkom ovog stoljeća tim putem snažnije su krenuli i Odjel ginekološke citologije Klinike za ginekologiju i porodništvo KBC Rijeka i Odjel za kliničku citologiju KB Osijek, svrstavajući se tako među naše vodeće laboratorije. U razdoblju od 1967. do 1974. godine u Hrvatskoj je osnovana organizirana nastava za citotehnologe (Tečaj za trajno usavršavanje citoskrinera 1968. godine) i citologe (Poslijediplomski studij iz Medicinske citologije 1967. godine i istoimena samostalna specijalizacija 1974. godine; studij i specijalizacija kasnije su preimenovani u Klinička citologija). Zahvaljujući dugogodišnjem radu 2005. godine u Hrvatskoj postoji razvijena ginekološka djelatnost s 33 laboratorija u kojima su 72 citotehnologa i 50 citologa analizirali 454 619 Papa testova. Taj potencijal ginekološke citologije od presudnog je značaja u sekundarnoj prevenciji raka vrata maternice sa ciljem smanjenja incidencije i mortaliteta, a u okviru dobro osmišljenog, organiziranog i kontroliranog nacionalnog probira u Hrvatskoj, koji bi uključio i nove metode, prvenstveno HPV tipizaciju.In Croatia, like in the rest of Europe, gynecologists were the first to perform microscopic analysis of cervical cytological specimens. The first laboratory headed by E. Baršić, a gynecologist, was established in 1953 at University Department of Gynecology, School of Medicine, University of Zagreb, now University Department of Gynecology and Obstetrics, Zagreb University Hospital Center. Jasna Ivić, MD was the first to devote exclusively to gynecologic cytology since 1959. In 1968, she was appointed Head of the Laboratory of cytology, which developed into Institute of Gynecological Cytology in 1984; Jasna Ivić organized cytology service in line with the principles adopted worldwide, and is most credited for the progress of gynecological cytology in Croatia. During the past fifty years, Institute of Gynecological Cytology in collaboration with other institutions, Department of Cytology and Clinical Genetics, University Department of Gynecology and Obstetrics, Merkur University Hospital – Zagreb in particular, has stimulated continuous development of gynecological cytology in the professional, scientific and educational aspects in Croatia, while promoting due recognition of the Croatian gynecological cytology abroad. At the beginning of the third millenium, these efforts have also been intensified at Department of Gynecological Cytology, University Department of Gynecology and Obstetrics, Rijeka University Hospital Center and Department of Clinical Cytology, Osijek University Hospital, which also became the leading laboratories in the field in Croatia. In the period 1967–1974 organized education of cytotechnologists (Continuing education course for cytotechnologists in 1968) and cytologists (Postgraduate Study in Medical Cytology in 1967 and respective independent residency in 1974, both subsequently renamed as Clinical Cytology) was established. Both played a key role in the development of clinical as well as gynecological Cytology in Croatia. According to the Croatian Society of Clinical Cytology of the Croatian Medical Association (CMA) survey in 2005 454 619 Pap tests were performed by 72 cytotechnologists and 50 cytologists in 33 laboratories. This potential of gynecological cytology is of decisive importance in the secondary prevention of cervical carcinoma through properly designed, organized and controlled national screening programme to be carried out in Croatia, which should include new methods, HPV typing before all

CLINICAL RECOMMENDATIONS FOR DIAGNOSING, TREATMENT AND MONITORING OF PATIENTS WITH UTERINE CERVICAL CANCER – CROATIAN ONCOLOGY SOCIETY AND CROATIAN SOCIETY FOR GYNECOLOGY AND OBSTETRICS AS CROATIAN MEDICAL ASSOCIATION UNITS AND CROATIAN SOCIETY OF GYNECOLOGICAL ONCOLOGY

Rak vrata maternice, u odnosu na malignome drugih ginekoloških sijela, jest bolest mlađih žena koja se može redovitim kontrolama i zdravstvenim odgojem prevenirati, a u slučaju pojave bolesti učinkovito liječiti. Metode liječenja uključuju kirurgiju, radioterapiju i kemoterapiju, ovisno o stadiju bolesti i općem stanju bolesnica. Odluku o liječenju donosi multidisciplinarni tim. S obzirom na važnost ove bolesti, potrebno je definirati i provoditi standardizirani pristup u dijagnostici, liječenju i praćenju ovih bolesnica. U tekstu koji slijedi iznesene su kliničke smjernice s ciljem implementacije standardiziranih postupaka u radu s bolesnicama s rakom vrata maternice u Republici Hrvatskoj.Cervical cancer, in comparison with other gynecological malignancies, mainly affects younger women. It can be prevented trough educational programs, screening and early detection. It also can be efficiently treated when it appears. Treatment modalities include surgery, chemotherapy and radiotherapy, according to the stage of the disease and patient condition. Treatment decisions should be made after multidisciplinary team discussion. Due to the significance of this disease it is important to define and implement standardized approach for diagnostic, treatment and monitoring algorithm as well. The following text presents the clinical guidelines in order to standardize the procedures and criteria for the diagnosis, management, treatment and monitoring of patients with uterine cervical cancer in the Republic of Croatia