Kornkanok Sukpan

Mucinous tumor of low malignant potential ("borderline" or "atypical proliferative" tumor) of the ovary: a study of 171 cases with the assessment of intraepithelial carcinoma and microinvasion.

Mucinous tumors of the ovary are a continuing source of controversy in the field of gynecologic pathology. We examined a series of 171 intestinal-type mucinous tumors of low malignant potential (“borderline” or “atypical proliferative” tumors) to clarify the clinical significance of intraepithelial carcinoma (IECA) and microinvasion (area ⩽10 mm2). The diagnosis of IECA was based on the presence of marked nuclear atypia (grade 3). Stromal microinvasion was classified as low grade and high grade (with nuclear grade 3). IECA was observed in 67 of 171 cases (39.2%). Microinvasion was identified in 31 (18.1%) cases, low grade in 22 (12.9%) cases, and high grade in 9 (5.3%) cases. Follow-up status was known in 144 cases and tumor recurrence was observed in 6 patients (4.2%). The risk factors for recurrence included International Federation of Gynecology and Obstetrics stage ≥IC (P=0.002), microinvasion (P=0.013), age less than 45 years (P=0.032), and IECA (P=0.042). The amount of IECA ≥10% was also associated with the risk of recurrence (P=0.007). Among tumors with microinvasion, there was no significant association between the clinicopathologic variables and recurrence. When considering tumors with stage ≥IC, tumor recurrence was significantly associated with IECA ≥10% (P=0.031) and age less than 45 years (P=0.047). It is important that mucinous tumors of low malignant potential should be staged and be optimally sampled for pathologic examination to document the status of the external surface or peritoneal involvement and to identify the worst degree of epithelial proliferation. Tumor stage ≥IC, IECA ≥10%, microinvasion, and age less than 45 years were the features that were associated with tumor recurrence. The study results also support the use of nuclear grade 3 as the sole criterion of IECA.

Numerous Intracystic Floating Balls as a Sonographic Feature of Benign Cystic Teratoma Report of 5 Cases

Objective. The purpose of this series was to describe the unusual but unique sonographic pattern of mature cystic teratoma. Methods. Five patients of reproductive age with clinical manifestations of a pelvic mass were evaluated with sonography for treatment planning. Results. All 5 cases showed the similar sonographic pattern of a large cystic tumor filled with multiple echogenic spherical structures floating in the cystic background. Of the 5 patients, 3 had rather large balls varying in size between 1 and 4 cm in the same tumor masses, whereas the other 2 had numerous smaller balls of about 0.5 cm in diameter. The numerous crowded very small echogenic balls in the last 2 cases mimicked solid nodules representing malignancy. However, there was no vascularization in the balls, which suggested a benign nature. The postoperative pathologic diagnosis was mature cystic teratoma without any malignant component in all cases. Conclusions. The sonographic feature of intracystic floating echogenic balls is probably pathognomonic for mature teratoma and is easily detected in most cases. Color Doppler sonography is helpful in differentiating these benign nodules (small balls) from malignant tumors.

Accuracy of Frozen-section Diagnosis of Ovarian Mucinous Tumors

Objective The objective of the study was to evaluate the diagnostic accuracy of intraoperative frozen sections of ovarian mucinous tumors and to identify the features associated with an inaccurate diagnosis. Methods Cases of ovarian mucinous tumors (benign, low malignant potential [LMP] or borderline, primary malignant, and metastatic) diagnosed by frozen section or final histology were recruited. Frozen-section diagnoses were compared with the final histologic diagnoses. Possible variables associated with diagnostic discrepancy were analyzed. Results A comparison of the diagnoses was done in 195 cases (102 benign, 61 LMP, 18 primary malignant, and 14 metastatic). Diagnostic agreement was observed in 164 cases (84.1%) and discrepancy in 31 cases (15.9%). The sensitivity of frozen-section diagnosis was low in LMP (67.2%) and malignant tumors (55.6%). The specificity was the lowest in the benign category (78.5%). The positive predictive values of all categories were less than 90% (range, 83.3%–85.7%). Diagnostic discrepancy was associated with tumor size of greater than 13 cm (P = 0.019) and the number of frozen sections of 4 or more (P = 0.035). However, in a multivariate analysis, there was no independent predictor of diagnostic discrepancy. The number of frozen sections 4 or more was strongly associated with tumor size of greater than 13 cm (P = 0.004). Conclusions The sensitivity of frozen-section diagnosis of LMP and malignant mucinous tumors was low. The inaccuracy of a frozen-section diagnosis of ovarian mucinous tumors may be related to a tumor size of greater than 13 cm. Increasing the number of intraoperative samples over 3 sections per case may not effectively increase the accuracy of frozen-section diagnosis in mucinous tumors.

HPV genotyping in neuroendocrine carcinoma of the uterine cervix in northern Thailand

To determine the distribution of HPV genotypes in cervical neuroendocrine carcinoma (NECA) in northern Thailand, and evaluate the correlation between HPV genotype and clinicopathologic features.

Fetal Cytomegalovirus Infection Associated with Cerebral Hemorrhage, Hydrops Fetalis, and Echogenic Bowel: Case Report

We describe some fetal ultrasound findings associated with intrauterine cytomegalovirus (CMV) infection. We report a 38-year-old gravida 3, para 2 at 16 weeks of gestation who underwent ultrasound examination for anomaly screening. The scan revealed an extensive irregular echogenic area in the fetal brain, especially at the level of lateral ventricles, suggestive of intraventricular and cerebral hemorrhage. Cardiomegaly, hepatomegaly, and mild ascites as well as an echogenic bowel were demonstrated. Abnormal chromosomes and hemoglobin Bart disease were excluded by analysis of fetal blood. Follow-up ultrasound at 20 weeks of gestation showed frank hydrops fetalis, and termination of the pregnancy was performed based on the couple’s decision, giving stillbirth to a male fetus weighing 450 g. Autopsy findings showed intracerebral hemorrhage (right cerebral hemisphere) and hydrops fetalis with hepatosplenomegaly. Microscopic investigation showed typical changes of CMV infection in several organs, including brain, thyroid gland, lung, liver, kidney, heart, pancreas, and placenta. Sonographically, the combination of hydrops fetalis, cerebral hemorrhage, and hyperechoic bowel should raise the possibility of a CMV infection, particularly in cases with no obvious cause of hydrops fetalis.

Cyclooxygenase-2 expression in squamous cell carcinoma of the uterine cervix is associated with lymph node metastasis.

OBJECTIVES Previous studies have indicated that cyclooxygenase-2 (COX-2) activity is related to the development and progression of cervical cancer. In this study, we evaluated the association between COX-2 expression and specific clinicopathologic features in surgically-treated squamous cell carcinoma of the uterine cervix. METHODS Immunohistochemical staining for COX-2 was performed on 196 cases of stage IB-IIA cervical squamous cell carcinoma. Results were correlated with the clinicopathologic features and disease-free survival using statistical analysis. RESULTS Expression of COX-2 was detected in 48.5% of cases. COX-2 expression was significantly associated with lymph node metastasis (p=0.045) but lacked significant correlation with tumour stage, size, histologic grade, deep stromal invasion, lymphovascular space invasion, and parametrial involvement. In multivariate analysis, only parametrial involvement and lymphovascular space invasion (LVSI) were independent predictors for lymph node metastasis (p=0.001 and 0.007, respectively). COX-2 expression was not associated with lymph node metastasis in the absence of parametrial involvement or LVSI. In the cases with LVSI, COX-2 expression was significantly associated with lymph node metastasis (p=0.03), although with marginal significance (p=0.068) in the multivariate analysis. COX-2 expression was not associated with a decrease in disease-free survival for patients overall (p=0.977). However, in patients who did not receive adjuvant treatment, COX-2 expression was significantly associated with decreased disease-free survival (p=0.008) and was a significant predictor of recurrence (p=0.014). CONCLUSIONS In this study, COX-2 expression was associated with lymph node metastasis in cervical squamous cell carcinoma, but this was linked to the presence of LVSI or parametrial involvement. This suggests that COX-2 expression may enhance lymph node metastasis after LVSI occurs. If so, immunohistochemical staining for COX-2 may provide additional prognostic information in LVSI-positive cases, in particular in patients who do not receive postoperative adjuvant treatment.

IOTA Simple Rules in Differentiating between Benign and Malignant Ovarian Tumors

BACKGROUND To evaluate the diagnostic performance of IOTA simple rules in differentiating between benign and malignant ovarian tumors. MATERIALS AND METHODS A study of diagnostic performance was conducted on women scheduled for elective surgery due to ovarian masses between March 2007 and March 2012. All patients underwent ultrasound examination for IOTA simple rules within 24 hours of surgery. All examinations were performed by the authors, who had no any clinical information of the patients, to differentiate between benign and malignant adnexal masses using IOTA simple rules. Gold standard diagnosis was based on pathological or operative findings. RESULTS A total of 398 adnexal masses, in 376 women, were available for analysis. Of them, the IOTA simple rules could be applied in 319 (80.1%) including 212 (66.5%) benign tumors and 107 (33.6%) malignant tumors. The simple rules yielded inconclusive results in 79 (19.9%) masses. In the 319 masses for which the IOTA simple rules could be applied, sensitivity was 82.9% and specificity 95.3%. CONCLUSIONS The IOTA simple rules have high diagnostic performance in differentiating between benign and malignant adnexal masses. Nevertheless, inconclusive results are relatively common.

Epstein-Barr virus-associated smooth muscle tumor presenting as a vulvar mass in an acquired immunodeficiency syndrome patient: a case report.

Smooth muscle tumors in immunocompromised patients have a strong association with Epstein-Barr virus (EBV) infection. EBV-associated smooth muscle tumors (EBV-SMT) are considered as a distinct group of smooth muscle tumors with different clinicopathologic features from conventional smooth muscle tumors. A 31-year-old female patient presented with a 2-cm mass at the left labium majus, the clinical diagnosis of which was a Bartholin lesion. She had acquired immunodeficiency syndrome diagnosed 29 months before. Excisional biopsy revealed a cellular tumor composed of round- to spindle-shaped cells with mild to moderate nuclear atypia. The tumor cells were immunoreactive for smooth muscle actin and muscle actin (HHF-35). Evidence of EBV infection was confirmed by in situ hybridization for EBV-encoded small RNA-1. To our knowledge, this is the first case of EBV-SMT presenting as a vulvar mass. EBV-SMT should be included in the differential diagnoses of mesenchymal tumor in patients with immunosuppression and in the differential diagnoses of smooth muscle tumor in uncommon sites, including the vulva.

Pattern recognition using transabdominal ultrasound to diagnose ovarian mature cystic teratoma

To determine the validity of sonographic pattern recognition in the diagnosis of mature cystic teratoma.

Population-based Cervical Cancer Screening Using High-risk HPV DNA Test and Liquid-based Cytology in Northern Thailand

BACKGROUND Northern Thailand is a region with a high cervical cancer incidence. Combined high-risk HPV (hrHPV) DNA testing and cytology (co-testing) has increasingly gained acceptance for cervical cancer screening. However, to our knowledge, data from a population-based screening using co-testing have not been available in this region. This study therefore aimed to evaluate the performance of cytology and hrHPV test in women in northern Thailand. MATERIALS AND METHODS Cervical samples were collected for hybrid capture 2 (HC2) testing and liquid-based cytology from women aged 30 to 60 years who were residents in 3 prefectures of Chiang Mai in northern Thailand between May and September 2011. Women with positive cytology were referred to colposcopy, while women with positive for HC2 only were followed for 2 years. RESULTS Of 2,752 women included in this study, 3.0% were positive in both tests, 4.1% for HC2 only, and 1.3% had positive cytology only. At baseline screening, positive HC2 was observed in 70.6% among cytology-positive women compared with 4.3% among cytology-negative women. The prevalence of positive HC2 or cytology peaked in the age group 35-39 years and was lowest in the age group 55-60 years. High-grade squamous intraepithelial lesion or worse lesions (HSIL+) were histologically detected in 23.5% of women with positive baseline cytology and in 9.8% of women with positive baseline HC2 only on follow-up. All women with histologic HSIL+ had positive baseline HC2. CONCLUSIONS The hrHPV test is superior to cytology in the early detection of high-grade cervical epithelial lesions. In this study, the prevalence of histologic HSIL+ on follow-up of women with positive hrHPV test was rather high, and these women should be kept under careful surveillance. In northern Thailand, hrHPV testing has a potential to be used as a primary screening test for cervical cancer with cytology applied as a triage test.