Flavio Grauso

Cannabinoid receptor type 1 immunoreactivity and disease severity in human epithelial ovarian tumors

OBJECTIVE In light of recent findings indicating that endocannabinoid system has antitumor actions, our study aimed to localize it in the human epithelial ovarian tumors, highlighting the differences among benign, borderline, and invasive forms and correlating cannabinoid receptor type 1 (CB1R) expression with disease severity. STUDY DESIGN We determined CB1R immunohistochemical expression in 66 epithelial ovarian tumors treated in the Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, at S. Maria del Popolo degli Incurabili Hospital (Naples): 36 borderline ovarian tumors, the main target of interest being intermediate forms, 15 benign and 15 invasive ovarian tumors. RESULTS The benign ovarian tumors showed a weak expression of CB1R in the 33% of the cases and moderate expression in the 67% of the cases. Borderline ovarian tumors had a similar trend. They showed weak CB1R expression in 28% of the cases, moderate expression in 53% of the cases, and strong expression in 19% of the cases. In contrast, invasive tumors showed a weak expression of CB1R in 7% of the cases, moderate expression in 20% of the cases, and strong expression in 73% of the cases. CONCLUSION The recorded data show that the expression of CB1R increased from benign and borderline to malignant tumors. In the near future, endocannabinoid receptors might be used in clinical practice, alone or in combination with other markers, to identify or better characterize ovarian tumors, without considering the great opportunity that they might represent as therapeutic targets.

Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm.

In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.

Borderline ovarian tumors: features and controversial aspects

OBJECTIVE To investigate features and controversial aspects of the borderline ovarian tumor (BOT), a neoplasm with favorable prognosis representing 10-15% of epithelial ovarian tumors. STUDY DESIGN : We retrospectively studied all patients treated at our institution from 2000 to 2010 taking into account the age, the stage, the type of surgery, the tumor size, the symptoms, the pre- and post-intervention tumor marker levels (CA125, CA19.9, CA15.3 and CEA), the presence of recurrence, the overall survival (OS), the progression-free survival (PFS). RESULTS A total of 43 patients were identified. The median age was 49 years (range: 15-82 years). The most frequent FIGO stage was IA (74% of the cases) with a prevalence of serous histotype, and 49% of the patients were asymptomatic. The CA125 level was abnormal in 55% of the patients before surgery, returning to the normal range in all cases after tumor removal. The PFS was 96% and 77% at five and sixty months respectively. CONCLUSION The BOT is closer to a benign than to a malignant tumor in the early stages, when confined to the ovary (IA and IB). In these stages conservative surgery is safe and advisable for women seeking offspring. In the other stages the need for a careful and long-term follow-up arises. CA125, despite its modest sensitivity and specificity, has a role in the follow-up of BOT.

Undifferentiated pleomorphic sarcoma with osteoclast-like giant cells of the female breast

The authors describe a case of undifferentiated pleomorphic sarcoma of the breast occurring in a 50-year-old woman who presented with a palpable mass in her right breast. She first noticed the mass one month previously. Core needle biopsy showed connective tissue including epithelioid and spindle cells. The patient underwent total mastectomy without axillary lymph node dissection. Based on examination of the excised tumor, the initial pathologic diagnosis was atypical spindle-shaped and ovoid cells with uncertain malignant potential. Histological findings with immunomarkers led to the final diagnosis of undifferentiated pleomorphic sarcoma.This case highlights a rare and interesting variant of primary breast sarcoma and the important role of immunohistochemistry in defining histological type and differential diagnosis. Hence, undifferentiated pleomorphic sarcoma has been a diagnosis of exclusion performed through sampling and critical use of ancillary diagnostic techniques.

Adding Agnus Castus and Magnolia to Soy Isoflavones Relieves Sleep Disturbances Besides Postmenopausal Vasomotor Symptoms-Long Term Safety and Effectiveness

The effectiveness for vasomotor symptoms and sleep disorders plus the long-term safety of a nutraceutical combination of agnus-castus and magnolia extracts combined with soy isoflavones (SI) and lactobacilli were assessed in postmenopausal women. A controlled study was carried out in menopausal women comparing this nutraceutical combination (ESP group) with a formulation containing isoflavones alone (C group) at the dosage recommended. The Kuppermann index, The Pittsburgh Sleep Quality Index (PSQI), and Short Form 36 (SF-36) were determined at baseline, three, six and 12 months. Endometrial thickness, mammary density and liver function were evaluated at baseline and after 12 months. One hundred and eighty women were enrolled in the study (100 in the ESP group and 80 in the C group). At the end of the treatment, mammary density, endometrial thickness, and hepatic function did not show substantial differences between groups. The Kuppermann index and particularly the tendency for hot flashes progressively and significantly decreased in frequency and severity during ESP versus C treatment. At the same time, a significant increase in sleep quality and psychophysical wellness parameters was observed in the ESP versus C groups. No adverse events were observed. Agnus-castus and magnolia, combined with SI + lactobacilli, can effectively and safely be used in symptomatic postmenopausal women, mainly when quality of sleep is the most disturbing complaint. The endometrium, mammary glands and liver function were unaffected after 12 months of treatment.

Laparoscopic Management of Bilateral Ovarian Torsion Following Ovarian Hyperstimulation Syndrome in a Twin Pregnancy

Ovarian accidents requiring surgical intervention during pregnancy should be accurately evaluated to identify the patients who need prompt surgical interventions from those where a “wait-and-see” strategy can be followed. The benefits and safety of minimally invasive surgery are well known in non-pregnant patients, but during pregnancy the risks of laparoscopic approach seems to increase. This is the first case reported in the international literature with bilateral ovarian torsion following ovarian hyperstimulation syndrome in a twin pregnancy, which was successfully managed by laparoscopic ovarian detorsion and unilateral adnexectomy. Increasing evidence suggests that laparoscopic treatment of adnexal masses in pregnancy is safe and effective although it is a surgical challenge with difficulty level that increases with gestational age. For this reason, laparoscopic surgery during pregnancy should be reserved for experienced surgeons able to reduce the additional risks and operating time.

Conservative Resectoscopic Surgery, Successful Delivery, and 60 Months of Follow-Up in a Patient with Endometrial Stromal Tumor with Sex-Cord-Like Differentiation

Uterine tumors with sex-cord-like differentiation are extremely rare types of uterine stromal neoplasm. These tumors were classified into two groups with considerable practical relevance because clinical behaviour of uterine tumor resembling ovarian sex cord tumor (UTROSCT) differs widely from its closely related endometrial stromal tumors with sex-cord-like elements (ESTSCLE). Treatment and prognosis of these tumors are unresolved issues because of the exiguous number of reported cases. We describe a rare case of endometrial stromal tumor with sex-cord-like differentiation successfully treated by resectoscopic surgery and conservation of the uterus, in an infertile patient affected by metrorrhagia. This procedure resulted in a pregnancy immediately after treatment and in a successful delivery. During 60 months of follow-up no evidence of recurrence was observed.

Vaginal angiomatosis: differential diagnosis of a rare case.

Vaginal angiomatosis is regarded as part of a very rare entity of benign vascular tumors of the female genital tract. The incidence of these tumors is extremely low. The rarity of this disease and lack of distinctive features poses a problem of differential diagnosis. We present the case of a 51-year-old female with grade III uterine prolapse and a bleeding vaginal wall mass. Violaceous irregular soft tissue with hemorrhagic spots was observed in the lower third of the posterior vaginal wall. The patient underwent surgery for colpohysterectomy with vaginal wall mass excision. Surgical excision was curative, and no recurrences were observed after 12 months of follow-up. The aim of our study is to present a rare but representative case. This will hopefully increase the level of awareness regarding this condition so that physicans will keep it in mind during differential diagnosis of similar clinical cases. Furthermore, it highlights the important role of pathological examination for the definitive diagnosis of angiomatosis.