Carmine Carriero

Skin metastases in ovarian carcinoma: a report of nine cases and a review of the literature

OBJECTIVE Cutaneous involvement is unusual at presentation and during the course of ovarian carcinoma. The aim of the present study was to determine the incidence, clinicopathologic characteristics and prognostic factors of skin metastases in ovarian cancer patients. METHODS A retrospective chart review was conducted on 220 patients with epithelial ovarian carcinoma treated at our unit between 1991 and 2001. Pertinent clinical information, pathologic data, treatment, and prognostic factors for survival following documentation of skin metastases were collected. Survival time was calculated from the time of diagnosis of ovarian cancer and from the time of diagnosis of the cutaneous metastasis. RESULTS FIGO stage at the time of ovarian cancer diagnosis was stage III = five patients (56%), and stage I and stage IV = two patients each (22%). Most patients had serous papillary cystoadenocarcinoma of the ovary (78%), and one each had endometrioid and mucinous carcinomas (12%). Seven patients (78%) had poorly differentiated tumors. Only one patient had a skin metastasis at the time of ovarian cancer diagnosis; in the remaining patients the average time of appearance of skin metastases after the diagnosis of ovarian cancer was 23.4 +/- 12 months (range 4 to 37). The diameter of the skin lesions ranged between 0.5 and 3 cm. Three patients had a single skin nodule, while six had multiple skin lesions. Eight patients (89%) have died of disease and median survival after diagnosis of the skin metastases was 4 months (range 2 to 65). One patient (Cases 1) is alive without tumor 4 months after diagnosis of the skin metastases. Overall survival after diagnosis of skin metastasis from ovarian cancer was 4 months (range 2 to 65). CONCLUSION Skin involvement is a late complication that occurs rarely in ovarian cancer patients. Prognosis after skin metastases is poor and the most important prognostic factor associated with survival is the interval time between diagnosis of ovarian cancer and documentation of cutaneous involvement.

The effect of a soy rich diet on the vaginal epithelium in postmenopause: a randomized double blind trial

BACKGROUND A traditional asiatic phytoestrogen-rich diet is associated with a lower incidence of estrogen-dependent cancers and clinical consequences of postmenopausal estrogen deficiency. First Wilcox in 1990, showed an increase of the vaginal cell maturation with phytoestrogens on postmenopausal women, but this has not been confirmed in some subsequent studies. METHODS In this study, we analyzed the effects of a 6-month soy-rich diet on the vaginal epithelium of asymptomatic postmenopausal women in a randomized clinical trial. 187 women were recruited for the study and divided into three groups: a phytoestrogen rich diet group; a hormonal replacement group, and a control group. A vaginal sample for hormonal cytology was taken before and at the end of the study, and sent unnamed to a cytologist. RESULTS The karyopycnotic index (KI) increased significantly in the diet group and in the HRT group but not in the control group. The maturation value (MV) had an identical trend to the KI. CONCLUSION We conclude that a soy rich diet is efficacious in increasing the maturation indices of vaginal cells. This effect could be a useful marker of the efficacy of a dietary intervention with phytoestrogen rich foods, and should be considered during preventive interventions against menopausal effects and vaginal atrophy.

Uterine cavity assessment in infertile women: comparison of transvaginal sonography and hysteroscopy

OBJECTIVES To evaluate the diagnostic accuracy of transvaginal sonography (TVS) in detecting uterine cavity abnormalities in infertile patients, with reference to hysteroscopy as the gold standard method. STUDY DESIGN At the Institute of Obstetrics and Gynaecology, University of Bari, 134 infertile women were investigated with both TVS and hysteroscopy. In all cases endometrial biopsy was performed. Sensitivity, specificity, and positive and negative predictive values were calculated for TVS, considering hysteroscopic diagnosis as the gold standard. Statistical analysis was performed by using McNemar test. RESULTS There was one failed insertion of hysteroscope. Hysteroscopy diagnosed pathological findings in 58 out of 133 cases (44%). TVS was in agreement with 50 of the 58 (86%) of the pathological findings diagnosed at hysteroscopy. As a test for the detection of uterine cavity abnormalities, TVS in comparison with hysteroscopy had 84.5% sensitivity and 98.7% specificity, 98.0% positive predictive value and 89.2% negative predictive value. CONCLUSIONS TVS is able to diagnose polyps, septum and submucous fibroids with quite significant accuracy, while hysteroscopy is indicated for their confirmation and removal. Thus, hysteroscopy provides both diagnostic and therapeutic capabilities, but TVS permits to proceed directly to operative hysteroscopy avoiding the need for a separate diagnostic procedure.

Groin recurrence in carcinoma of the vulva: management and outcome

The aim of the study was to investigate the management and outcome of inguinal recurrence in vulvar carcinoma patients. A retrospective chart review was conducted on 140 patients with squamous cell carcinoma of the vulva treated between 1994 and 2006. Twenty-one patients were found to have groin recurrence. Median interval between primary treatment of vulvar cancer and groin recurrence was 7 months. Three patients refused any treatment, 3 received chemotherapy, 2 inguino-pelvic radiotherapy and 13 had resection of the groin recurrence. After surgery seven patients received irradiation of the groin and pelvis, and three patients received chemotherapy. One patient died following surgery; 19 patients died of disease with the median survival after diagnosis of inguinal recurrence of 9 months. Only one patient is alive without evidence of disease at 60 months following surgery. In univariate analysis, stage and grade at diagnosis, age and performance status at the recurrent disease, and the extent of residual tumour after resection of groin recurrence were predictors for survival. Groin recurrences from vulvar carcinoma carry a poor prognosis. Multi-modal treatment may result in a palliation of the disease, and a very limited number of patients have long-term survival.

Cisplatin and Vinorelbine Chemotherapy in Recurrent Vulvar Carcinoma

Purpose: To evaluate the activity and toxicity of the combination of cisplatin and vinorelbine in patients with recurrent carcinoma of the vulva that has not been previously treated with chemotherapy. Patients and Methods: Sixteen women with a median age of 65 years (range 43–79) with recurrent vulvar carcinoma were enrolled in the study. Nine patients had local recurrent disease (perineum, vagina and/or vulva), whereas 7 had disease in the groin; 9 patients had received prior radiotherapy. Cisplatin was administered intravenously on day 1 and vinorelbine was given on day 1 immediately after cisplatin and on day 8. Results: A total of 68 cycles of chemotherapy were administered. Fifteen women were assessed for response. Objective responses were recorded in 6 patients (40%) – with 4 patients (27%) achieving a complete response and 2 (13%) achieving a partial response –, whereas 4 patients (27%) had stable disease and 5 had progressive disease. The median progression-free survival was 10 months (range 3–17), whereas the overall survival from the beginning of the chemotherapy was 19 months (range 1–30). Due to the small number of patients, no significant correlation with site of recurrence could be found. Conclusion: The combination of cisplatin and vinorelbine is a well-tolerated and active regimen in the treatment of patients with recurrent vulvar carcinoma.

Carcinosarcoma of the vulva: A case report

Carcinosarcoma is a well‐recognized tumor even if it is an uncommon entity. Neoplasms usually occur in the oral cavity, pharynx, esophagus, larynx and skin, and have been rarely documented in the female genital tract. This case reports a patient with a diagnosis of vulvar carcinosarcoma that has been treated with radical vulvectomy and a left inguinal lymphadenectomy but she died two months later of progressive disease. Because of the extreme rarity and severe prognosis of the tumor, we believe that this is a useful addition to the literature and might serves as a reminder to physicians that a multidisciplinary approach for management should be undertaken for treatment.

Locally advanced cervical cancer associated with complete uterine prolapse.

Although uterine prolapse and carcinoma of the uterine cervix are not rare event, their association is very uncommon. An 86-year-old patient gravida 8, para 5 was admitted for vaginal bleeding from a uterine prolapse of 20 years of duration. On physical examination, a complete third-degree prolapsed uterus with an ulcerated lesion of 12 cm in maximum diameter involving both the anterior and posterior lips of the cervix was observed. Because of the poor performance status and high American Society of Anesthesiology scoring, the patient was admitted for a vaginal hysterectomy with upper vaginectomy in spinal anesthesia. However, she died of pulmonary embolism 20 days after surgery. A case of a cervical cancer with a complete uterine prolapse of 20 years of duration is reported. We believe that this case typically rare to see in a developed country might be a useful addition to the few published reports.

Assisted Reproductive Technology in Italy: Juridical and Ethical Considerations

to guarantee ethically correct behavior (3). The aim BARI, ITALY of the code was to establish certain rules, while waiting for a future law and considering the new Italian Code Assisted Reproductive Technology in Italy: of Medical Ethics, to guarantee the inalienable right Juridical and Ethical Considerations of a couple to try to have a child, together with respect to the safety and the rights of the future born. In article 1 of the code, it is stated that interventions must be Submitted: January 11, 2000 directed to couples of fertile age, heterosexual, marAccepted: February 11, 2000 ried, or steadily cohabitant. Women are allowed to receive ovodonation until the age of 51 years. Articles 2, 3 and 4 establish the preliminary care of the couple. INTRODUCTION In article 5, it is important to note that it is mandatory for every CECOS center to be equipped for collection and preservation of human gametes. Some cautions In Italy, 256 centers work on infertility problems: 70% for donors of sperm and ovocytes are stated in articles in private practice and 30% in public hospitals. Among public health institutes, 52.6% are in northern Italy, 6 and 7. It is worth notoing that article 9 states it is 19.2% in central Italy, and 28.2% in southern Italy. forbidden to use sperm that has been cryopreserved With regard to private centers, 50.8% are in the South, for personal use (autopreservation) after the death of while 25.7% and 23.5%, respectively, are in the norththe owner. Article 10 states that the cryopreservation ern central and sections of the country. of spare embryos is allowed. The maximum number Since 1968, De Vincentiis and Lauricella (1) pointed of transferred embryos is limited to four, as articulated out that in many European countries artificial insemiin article 11. Finally, article 13 sets limits on embryo nation, both homologous and heterologous, was curmanipulation, which is allowed only for diagnostic and rently performed, while in Italy the lack of legislation therapeutic reasons. Gender selection is allowed only caused embarrassment among gynecologists and parafor gender-linked diseases; embryo dissection, cloning, lyzed the centers that diagnose and treat infertility. and production of hybrids or human embryos for Ten years later, 1978, Lauricella (2:) reported: “A research only are forbidden. Enormous efforts have society which has produced modern laws on familiar been made to provide against lack of legislation. Since relationship determining the end of patriarchal family, 1994, the National Institute of Health, Epidemiology which has practically liberalised induced abortion, and Biostatistics Laboratory started the Italian National must not, for religious–ethical scruples of a party, Register on Medically Assisted Reproduction in order delay mandatory solutions for the serenity of many to monitor all cycles, offering the detailed picture of infertile couples, or for scientific and social aims.” what happens in the country and providing the necessary base for a correct national health policy in this field. THE SELF-REGULATION CODE OF To be complete, the Catholic Church’s official posiCECOS ITALIA tion also must be reported. In the evangelic letter, “Evangelum vitae,” Pope John Paul II confirms that biomedical technology goes well beyond a reasonable In 1992, still waiting for official legislation from the human domain on the nature, in particular in nontheraparliament on assisted reproductive technology (ART), peutic research and manipulation of human embryos, the Association CECOS Italia (Centre pour la Conservation du Sperm) elaborated the self-regulation code in their destruction or cryopreservation, in the selection

Colpocytological abnormalities in HIV infected and uninfected pregnant women: prevalence, persistence and progression

Abstract In this retrospective case-control study, we analyse data of 48 HIV-positive pregnant patients, versus a control group of 99 HIV-negative pregnant women, followed as outpatients by our department from 2009 to 2014. The aims of the study were to investigate the prevalence, persistence and progression of cervical squamous intraepithelial lesions (SIL) in each group and to correlate colpo-cytological lesions to the socio-demographic and clinical-laboratory findings in the HIV + pregnant women. In our study we observed that immunosuppression, HPV infection and vaginal coinfections were predictive of cervical lesions. Pap smear and colposcopy should be part of routine care for HIV-infected pregnant women because these lesions behave aggressively in these patients. Success of prevention depends on massive access of patients to screening. HAART reduces viral load and maintains CD4 count and can affect progression of SIL. Multidisciplinary services on the same site appear to be one promising strategy to improve compliance in patients. Impact Statement What is already known on this subject: Our study provided novel information on a highly vulnerable population of young HIV + pregnant women. What the results of this study add: We observed that immunosuppression, HPV infection and vaginal coinfections were predictive of cervical lesions remarkable with colposcopy. We could consider these important risk factors to evaluate to establish an appropriate strategy of management for these patients. What the implications are of these findings for clinical practice and/or further research: Association of the risk between SIL presence and HIV and HPV infection also deserves additional investigation. We believe that Pap smears and colposcopies should be part of the routine care for HIV-infected women because these lesions behave particularly aggressively in these patients.