Anna Stępniak

Primary ovarian Burkitt’s lymphoma: a rare oncological problem in gynaecology: a review of literature

PurposeThis review presents the information about epidemiology, clinical manifestation, diagnosis and treatment of primary ovarian Burkitt’s lymphoma (BL), including a literature search of available BL cases. The purpose of this review is to draw clinicians’ attention to the possibility of ovarian BL occurrence, which may be important in the differential diagnosis of ovarian tumours.MethodsPubMed and Web of Science databases were searched using the keywords ‘‘Burkitt’s’’, ‘‘Lymphoma’’, ‘‘Ovarian’’, ‘‘Primary’’, ‘‘Burkitt’s lymphoma’’. Only cases with histopathologically confirmed diagnosis of primary ovarian BL were included in this review.ResultsFifty articles, reporting cases with an ovarian manifestation of primary non-Hodgkin’s lymphoma, were found. Twenty-one cases with a histopathologically confirmed BL were evaluated to compare various manifestations, treatment and prognosis in ovarian BL.ConclusionsPrimary ovarian BL is a rare condition, included in the entity of non-Hodgkin lymphoma. The tumour can occur uni- or bilaterally in the ovaries with major symptoms such as abdominal pain or a large abdominal mass. Differential diagnosis, based on imaging features and pathological examination of the specimens, is essential for further treatment due to various aetiology of ovarian tumours. Although most of the patients suffering from ovarian BL underwent surgery after the ovarian tumour had been detected, surgical treatment is not the treatment of choice in patients with ovarian lymphoma. The mainstay of therapy is chemotherapy without further surgery. The prognosis is better if the chemotherapy protocol is more aggressive and followed by prophylactic central nervous system chemotherapy. Nowadays, multiagent protocols are administered, which improves the survival rate.

The influence of uterine artery embolisation on ovarian reserve, fertility, and pregnancy outcomes – a review of literature

Uterine fibroids are considered to be the most frequent female benign tumours. Fibroids affect mainly women of reproductive age. The most frequently reported signs and symptoms of fibroids include disturbances of the menstrual cycle such as heavy bleeding and painful menstruation, pelvic masses associated with pelvic pain, urinary problems or constipation, as well as infertility and recurrent pregnancy loss. The mainstay of fibroid treatment is still surgery. However, many patients seek alternative treatment options for fibroids, to preserve their uterus and fertility. One of the most important alternative treatment options for fibroids is uterine artery embolisation (UAE). However, there are some concerns that UAE may negatively influence ovarian function and even result in premature menopause. Moreover, the use of UAE in patients with future reproductive plans is still controversial, due to the possible pregnancy complications. The purpose of this review is to summarise the current knowledge regarding the possible influence of UAE on fertility, pregnancy outcome, and ovarian reserve.

The role of levonorgestrel intrauterine systems in the treatment of symptomatic fibroids

Uterine fibroids are considered to be the most frequently occurring tumours in females. The majority of fibroids do not require any treatment. When symptomatic, the major ailments include abnormal uterine bleeding, painful menstruation, pelvic pressure or pain, urinary problems, constipation, infertility, and recurrent pregnancy loss. Surgery remains a mainstay of symptomatic uterine fibroids therapy; however, minimally-invasive techniques and pharmacological management have become more available. The levonorgestrel intrauterine system (LNG-IUS) is a T-shaped device with a vertical stem containing a reservoir of levonorgestrel and is widely known for its contraception effect. Moreover, the non-contraceptive benefits of the LNG-IUS have been previously confirmed by numerous studies. LNG-IUS causes reduction of the duration and the amount of menstrual bleeding, with minimal side effects due to release of hormones at the targeted organ. Currently, results from systematic reviews show that LNG-IUS may be an effective and safe treatment for symptomatic uterine fibroids in premenopausal women. However, further studies are required to consolidate the usage of LNG-IUS in the treatment of symptomatic uterine fibroids.

3D Power Doppler vascular indices as a novel technique in assessing the outcome of minimally invasive techniques in uterine fibroids treatment

Uterine fibroids are considered to be the most frequent female benign tumours. The most common reported symptoms of fibroids are heavy menstrual bleeding and painful menstruation, pelvic pain, urinary problems, constipation, as well as infertility and recurrent pregnancy loss. The mainstay of fibroid treatment is surgery, but nowadays minimally-invasive techniques are growing in popularity. Vascularity of fibroids may play a role in the outcome of these techniques, which is why it is important to find an objective, reproducible technique to measure the vascularization before and after the procedure. The 3D Power Doppler vascular indices (3DPDVI) allow objective assessment of vascularization in the entire volume of the tumour. Initially this technique was mostly used in experimental imaging phantoms, but recently many studies focus on the clinical utility of this technique. Power Doppler allows to obtain information on vascularity in the area of interest, while 3DPDVI can be objectively calculated by the Virtual Organ Computer-aided AnaLysis (VOCAL™) software. 3DPDVI showed high reproducibility in most of the studies. This technique has an important role in monitoring the outcome of minimally invasive procedures in fibroid treatment, because they affect vascularity of the tumours. Although there are some limitations of 3DPDVI, it seems that their application may be an effective tool in objective assessment of vascularity of fibroids. However further studies are required to consolidate the usage of 3DPDVI in clinical practice.

The safety and tolerance of phytotherapies in menopausal medicine – a review of the literature

Phytoestrogens are polyphenol, non-steroidal substances of plant origin, resembling 17β-estradiol in structure. These substances can act as either agonists or antagonists of oestrogen receptors α and β. Phytoestrogens are widely used to alleviate menopausal symptoms, such as hot flushes and night sweats. Most of the currently available products of plant origin registered to soften climacteric symptoms consist of extracts obtained from soy, red clover, or black cohosh. Non-hormonal phytotherapy is a new alternative for patients suffering from menopausal symptoms. Active ingredients such as PI 82-GC FEM extract do not show any direct hormonal mechanisms of action typical for oestrogens and phytoestrogens. There are concerns about the safety and tolerability of phytoestrogens. In this review we summarise the current literature regarding the clinical aspect of safety and tolerance of different phytotherapies used to relieve menopausal symptoms.

Secondary dysmenorrhea due to a rudimentary, non-communicating functional uterine horn

Unicornuate uterus with a rudimentary horn is a rare congenital Müllerian anomaly, which may lead to many obstetrical and gynaecological complications. This pathology occurs in approximately 1/100 000 women. A rudimentary horn forms due to insufficient development of the Müllerian duct. The diagnosis of this anomaly is usually delayed, as it remains asymptomatic until adolescence and its main symptom is dysmenorrhea.

Pelvic congestion syndrome initially misdiagnosed as a hydrosalpinx — a diagnostic challenge

Pelvic congestion syndrome (PCS) is characterized by abnormalities of ovarian, internal iliac or parametrial veins such as: dilation, varices, valvular insufficiency, obstruction or local inflammatory process. Chronic pelvic pain (CPP) is the typical symptom of PCS. PCS is one of the most frequently underdiagnosed or misdiagnosed gynecological conditions. The differential diagnosis, including gynaecological, gastrointestinal, urological and neurologic disorders, plays an important role in the adequate recognition and further treatment. We report a case of a 41-year-old patient of Caucasian racial origin, gravida 3, para 3, admitted to the hospital due to deterioration of CPP. The patient was previously diagnosed with a hydrosalpinx in the outpatient setting and was awaiting laparoscopic treatment. CPP, with a year and a half duration, was the only complaint reported. Transvaginal ultrasound examination was performed using a UGEO WS80A ultrasound system (Samsung Medison, Seoul, Korea). The uterus appeared normal except for the presence of multiple tortuous arcuate veins in the myometrium (Fig. 1), the ovaries were bilaterally unremarkable, the suspicion of hydrosalpinx was not confirmed. A dilated (up to 10.4 mm) left parametrial venous plexus, which was probably mistakenly interpreted as a hydrosalpinx, was also seen (Fig. 2). Some ultrasound features of the dilated plexus, such as an anechoic mass with incomplete septa, separated from the ovary may have led to the initial outpatient misdiagnosis of a hydrosalpinx. Slow and retrograde blood flow was noted in the dilated plexus (Fig. 3). Valsalva manoeuver was performed during the examination to show the enhanced reversed blood flow. Basing on the ultrasound image of the pelvic veins the diagnosis of PCS was made. The patient was qualified for phlebography and embolization of the left ovarian vein using the femoral approach. During the procedure the diagnosis was confirmed by visualizing reflux in the abnormal left ovarian vein and left parametrial venous plexus. The abnormal veins were closed with the use of detachable coils and aethoxysclerol (Fig. 4). Immediately after the procedure and during 3 months follow-up the patient did not report any pain. Moreover, the ultrasound findings tended to regress, the dilated pelvic veins were not visualized at 3 months follow-up. PCS is often an overlooked condition, that can mimic other gynecological diseases, and can be effectively treated by minimally invasive techniques. Transvaginal ultrasound is the first line imaging modality to confirm the suspicion of PCS. Ultrasound diagnostic criteria for PCS are dilated pelvic or ovarian veins > 6 mm, reversed blood flow in the pelvic or ovarian veins, polycystic changes in the ovaries and dilated veins in the myometrium. The awareness of PCS is low. In our case, despite the fact that 3 out of 4 diagnostic criteria for PCS were met, the initial outpatient diagnosis was false. The diagnosis of PCS is challenging and PCS should not be omitted in the diagnostic investigation of CPP. Figure 1. Transvaginal ultrasound image of the uterus. Multiple tortuous arcuate veins (arrows) were seen in the myometrium

Amenorrhea after chemoembolization and suction curettage of caesarean scar pregnancy

LEARNING OBJECTIVES To better understand the management of caesarean scar pregnancy (CSP) and to be able to recognize and to manage a potential complication of an intervention used to treat CSP. CSP is a rare location of ectopic pregnancy implanted in the area of the previous caesarean section (CS) scar. CSP is associated with a high risk of haemorrhage and in severe cases even a necessity to perform life saving hysterectomy. Selective uterine artery chemoembolization with intra-arterial methotrexate (MTX) infusion followed by suction curettage is one of the treatment options available for CSP. Literature data on the possible complications of this treatment approach are scarce.

Unusual location of a plexiform neurofibroma in the fallopian tube: A case report

It is rare for neurofibromatosis to occur in the female genital tract. We report a case of a plexiform neurofibroma in the left fallopian tube in a 50‐year‐old postmenopausal woman. The initial diagnosis was a pedunculated leiomyoma or a fallopian tube tumor. Laparotomy was performed and a solid mass approximately 90 x 60 x 40 mm in size was found in the left fallopian tube. Total abdominal hysterectomy and bilateral salpingo‐oophorectomy with an appendectomy, lymphadenectomy and omentectomy was performed. The histopathological diagnosis was plexiform neurofibroma. Although neurofibromatosis may involve various gynecological structures, to the best of our knowledge, localized plexiform neurofibroma in the fallopian tube has not previously been reported. The presented case is the first report of clinical, ultrasound and histopathological findings in a fallopian tube neurofibroma. Neurofibroma is a neoplasm that should be taken into consideration when diagnosing pelvic masses.

Successful treatment of spontaneous heterotopic caesarean scar pregnancy by local potassium chloride injection with preservation of the intrauterine pregnancy

Heterotopic caesarean scar pregnancy (CSP) is a coexistence of an intrauterine pregnancy with an ectopic pregnancy located in a caesarean scar. The are no universal treatment guidelines to manage this extremely rare condition. Vaginal bleeding is the most common symptom of heterotopic CSP, but most of the cases are asymptomatic. The management of heterotopic CSP is difficult especially in patients who want to preserve the intrauterine pregnancy. A 33-years-old patient, one caesarean section (CS) in history, at 6 weeks of gestation was admitted to the hospital to confirm the diagnosis of ectopic pregnancy. On transvaginal ultrasound a heterotopic pregnancy was visualized. One gestational sac (GS) was located within the uterus cavity, another one was implanted in the anterior wall of cervicoisthmic area in the caesarean scar (Fig. 1). In both embryos the foetal heart rate was observed, the crown-rump length was 3.4 mm in the intrauterine pregnancy and 2.4 mm in the heterotopic CSP. The cervical canal was closed and measured 49 mm in length. There was no bleeding on the speculum examination. The patient was asymptomatic. Several treatment options were described in the literature: embryo aspiration of CSP, systemic or local injection of methotrexate, local injections of potassium chloride (KCl) or hyperosmolar glucose, laparoscopy or hysteroscopy. After being informed about the high risk of continuing the heterotopic CSP and possible complications of treatment, the patient decided to preserve the intrauterine pregnancy (IUP) and terminate the heterotopic CSP. Selective embryo termination was performed at 7 weeks of gestation by local ultrasound guided injection of KCl into the GS implanted in the caesarean scar. After the procedure the foetal heart rate was no longer visible in the heterotopic CSP, but confirmed in the IUP. Further pregnancy course was normal (Fig. 2) and there were no ultrasound abnormalities in the caesarean scar area (Fig. 3). The patient delivered a 3060g healthy male infant by elective CS at 37 weeks of gestation. The procedure and the puerperium were not complicated. During the CS only a minimal dehiscent was seen in the previous caesarean scar area (Fig. 4). Heterotopic CSP should be considered in patients with a CS in history, especially in cases where assisted reproductive technologies were used. Early diagnosis is the essential part of heterotopic CSP treatment. Transvaginal ultrasonography seems to be the ideal tool to detect heterotopic CSP in the 1st trimester. Early detection and treatment of heterotopic CSP increases the probability of preserving the IUP.