)
Table of contents :
))
from the breast
(mass effect on hypothalamus or compression of hypothalamic root)
secretion
(increased TRH,
which is also a releasing factor for PRL)
therapy
incretion,
breast bandage
gene may be potential candidate for lactation insufficiencies.
(ulceration in primary syphilis; acute mastitis in secondary syphilis;
gum in tertiary syphilis requires differential diagnosis with carcinoma)
or streptococcal bacteria and usually affecting lactating women; it may
be),
not associated with cigarette smoke; dilatation of of subareolar ducts
=> deposition of cellular debris and lipids => cronic interstitial granulomatous
inflammation.
Women, usually age 40-59 years. Associated with pituitary adenomas, increased
prolactin levels. Not associated with smoking; not related to fibrocystic
changes. Gross: skin retraction from fibrosis may mimic cancer; nipple
discharge in 20%. Micro: duct dilation, inspissation of secretions (cheesy),
periductal and interstitial granulomatous inflammation (granulomatous mastitis)
or plasma cells (plasma cell mastitis); ducts contain foamy macrophages;
increased elastic fibers in duct wall, calcification; no squamous metaplasia
of nipple ducts; no epithelial hyperplasia
(mainly large B cell lymphoma).
Associated with mild increased risk of carcinoma, especially with ductal
hyperplasia or family history of breast carcinoma. Malignant transformation
occurs in < 0.1%, usually DCIS. Infarction associated with pregnancy,
lactation, fine needle aspirationref.
Gross: sharply circumscribed, freely movable, spherical nodule, usually
3 cm or less; often in upper outer quadrant, gray-white, bulging cut surface;
20% multifocal. Micro: overgrowth of fibrous and glandular tissue; intralobular
stroma (delicate, cellular, myxoid or fibrotic) encloses glandular spaces;
may infarct, become inflammed, calcify; 15% have apocrine metaplasia; no
necrosis, no elastic tissue. Pericanalicular: open glandular spaces vs
intracanalicular: compression of glandular spaces [no clinical significance
to this distinction]. Glands composed of cuboidal/low columnar epithelium
without atypia, adjacent myepithelium. Rarely benign but pleomorphic, bizarre
multinucleated giant cellsref,
metaplastic cartilage, smooth muscle or adipose tissue; myxoid change (suggests
Carney’s syndrome of endocrine hyperactivity, cardiac myxoma and cutaneous
hyperpigmentation), fibrocystic features, sclerosing adenosis, squamous
metaplasia. Positive stains: PR. Negative stains: ER. DD: phylloides tumor
(cellular stroma), papillary carcinoma at FNAref
mutations, the possibility to develop breast cancer by age 50 may be as
high as 60%. Those who also have relatives with breast or ovarian cancer
have an 80% chance of developing breast cancer, compared with 10% in the
general population : the risk is also close to 80% for women with BRCA
mutations but no affected family member. Lifestyle is also important :
heterozygous women born after 1940 have a 67% risk of developing breast
cancer by the age of 50. For those born before 1940, the risk is only 24%.
Exercising and staying slim as a teenager tend to delay the age at which
women with mutations develop cancer by several years.,
with slight increases for those with...
have a RR = 2 : use of CHRT for 10 years is estimated to result in 19 extra
breast cancers per 1,000 users. Women using estrogen-only
replacement therapy (ERT)
have RR = 1.3, but ERT has been linked to a slightly increased risk of
developing endometrial adenocarcinoma
- which is why it tends to be given to those women who have undergone hysterectomy.
Users of HRT are more likely than newer users to develop breast cancer
(RR = 1.66) and die from it (RR = 1.22) : the risk begins to increase within
1-2 years of starting HRT. Interestingly, past users are not at increased
risk of developing or dying from breast cancer.
in postmenopausal women (obese women have about 3 times the circulating
estrogen
levels as lean women and also leptin
is a breast growth factor)
in underarm cosmetics (deodorants, ...) are transdermally absorbed : they
are found unmodified in 90% of breast tumor tissues with a mean concentration
of 20.6+/-4.2 ng/ g tissue = 1 part per 48m (comparison of individual parabens
showed that methylparaben was present at the highest level (with a mean
value of 12.8 +/- 2.2 ng/g tissue) and represents 62% of the total paraben
recovered in the extractions), but there is still no scientific evidence
of a causal link. The strongest supporting evidence comes from unexplained
clinical observations showing a disproportionately high incidence of breast
cancer in the upper outer quadrant of the breast, just the local area to
which these cosmetics are appliedref1,
ref2.
An earlier age (> 15 years younger) of breast cancer diagnosis is related
to more frequent use of antiperspirants/deodorants and underarm shaving
(> 2 times a week) : consistet with previous studies no link is found between
younger age of breast cancer diagnosis when either shaving or deodorant
is used aloneref.,
contained in many hard plastics which can leach into food after heating
and also appearing in some dental fillings and the linings of tin cans.
Industry began using bisphenol A in the 1950s, but in recent years scientists
have documented how it mimics the hormone oestrogen. Some scientists worry
that because oestrogen plays such a crucial role in the development of
a fetus's reproductive system and other organs, exposure to bisphenol A
in the womb could cause problems. A recent study of mice exposed in this
way found that the artificial compound caused abnormally high levels of
growth in the male animals' prostate glands. Now, another team of researchers
has investigated the effects of this chemical on female miceref.
The scientists hypothesized that bisphenol A could make breast tissue more
sensitive to the effects of oestrogen. So they exposed mouse fetuses to
a daily dose of 250 ng/kg of their body weight, < 1% the amount deemed
safe for humans in the USA. 4 days after birth, the scientists stopped
administering the chemical to the mice. They then waited until the animals
reached puberty at 30 days of age, and removed their ovaries. This allowed
them to deliver the mice's oestrogen themselves, so that they could measure
its influence in a controlled way. The mice exposed to bisphenol A while
in the womb developed significantly more tissue in parts of their mammary
glands than their control counterparts. The exposed mice had a 4-fold increase
in gland structures known as terminal end buds. This is important because
increased breast tissue density in humans is an established risk factor
for breast cancer. It's an important study because it's the first time
someone's showed that prenatal exposure to bisphenol A causes alterations
in mammary gland development. Although the findings focus on laboratory
animals, they may have implications for people. Testing the effects of
the chemical in humans would be difficult, as the study would have to monitor
exposure over 50 years from birth to the age at which breast cancer more
commonly occurs. Lawmakers in California are currently considering legislation
that would ban bisphenol A from children's toys.,
and CE-3,4-Q by conjugation with glutathione (GSH) or by reduction to CE,
catalyzed by quinone reductase and/or cytochrome P450 reductase. Females
homozygous for hypoactive forms of the catechol-inactivating enzyme COMT
are more susceptible to side effects of HRT.
: women who took antibiotics for > 500 days or had > 25 prescriptions for
antibiotics, over an average of 17 yrs, had twice the risk of breast cancer
as women who had taken no antibiotics. The association with breast cancer
risk might be mediated throgh the effects of the antibiotics on immune
and inflammatory factors, and disruption of phytochemical and estrogen
metabolism by intestinal microfloraref
intake : older women with a history of at least 30 grams of ethanol
abuse a day (roughly the equivalent of 2 drinks) have a 40% higher risk
than nondrinkers to be diagnosed with ER+ and PR+
tumors, a 330% increased risk of lobular cancer and a 50% increased risk
of ductal cancer. However, the studies relied on women's self-reports of
how much they drank and research shows that most people don't accurately
report their alcohol consumption.
increases a woman's chance of being left-handed (Scheirs J. G. M.&
Vingerhoets A. J. J. M. J. Clin. Exp Neuropsychol., 17. 25 - 30 (1995)).
But the full mechanism behind handedness remains elusive. Some scientists
think that clues to breast cancer also lie in the prenatal period of human
development. Studies in mice have found that fetal exposure to oestrogen-like
compounds can increase the risk of breast or prostate cancer in later life.
These 2 links to oestrogen-like chemicals could be creating an association
between handedness and cancer. After examining the records of over healthy
middle-aged women born between 1932 and 1941, left-handed pre-menopausal
women face double the risk of developing breast cancer as right-handed
women do. This trend did not apply, however, to women who had not given
birth or to those who were overweight or obeseref.
It is not the first study to focus on this association. Other, retrospective
studies have found a similar link between handedness and breast tumours.
But the Dutch team thinks their thorough approach lends more support to
the idea that the effect is real, and that chemicals in the womb could
be to blame. In some countries, bans are in place to prevent oestrogen-like
chemicals from being used in plastics. Others are campaigning to reduce
the amount of such chemicals flooding into our environment from contraceptives
and other sources.
gene. This is the first population-based study to report a clearly significant
increase in TP53 mutations that is independent of race differences in other
tumor characteristics, socioeconomic status and other biomedical and lifestyle
factors : past explanations for the racial/ethnic differences included
socioeconomic factors, nutrition and healthcare behavior, but while many
factors contribute to the relatively poor outcome for some African-American
breast cancer patients, understanding the underlying mechanisms is critical
in premenopausal women (probably by inhibiting ovulation by abnormal estrous
cyclicity, even though estradiol
concentrations don't differ between the lean and fat animals)
associated with highly aggressive tumours that have a poor prognosis. Not
only did oleic acid suppress over-expression of the gene, other tests on
the cell lines showed that it also boosted the effectiveness of anti-ERBB2
/ HER2 / neu mAbsref
T29C SNP confers a reduced risk of breast cancer among premenopausal, but
not postmenopausal, Japanese women.-
tumors)
is mutated in 8% of all breast cancers : susceptibility to breast cancer
occurs only in females who inherit a mutation in BRCA1 as mutated BRCA1
inhibits the non-coding XIST RNA localization to the Xi chromosome,
reactivating genes that are normally silent on the Xi
(deleted in 2% of cancers)
(amplified in 18% of breast cancer cell lines and 20% of samples from newly
diagnosed patients : the degree of amplification correlates with the expression
level. Also amplified in 17% of high-grade ovarian carcinomas) inhibits
normally functioning BRCA2
by binding to a a region (exon 3 in aminoterminus) that is deleted in cancer,
associated with chromatin regulators HP1b and
BS69, and it localized to sites of repair following DNA damage. Prognosis
: average survival of 6.4 years, compared with 14 yearsref.
The sequence of the first few amino acids of the protein coded for by EMSY
- serine-isoleucine-serine-threonine-glutamic acid-arginine — spells out
a word when the standard abbreviations for these amino acids are used.
The word is S-I-S-T-E-R, so the gene was named after the sister of one
the researchers, Luke Hughes-Davies. This was particularly appropriate
as Emma Hughes-Davies (called Emsy when she was young) is a breast cancer
nurse. The 80-amino-acid EMSY N-terminal domain (ENT) was found
in 9 Arabidopsis proteins that also contain a Royal-family domain,
designated Agenet, that can recognize lysine-methylated histones, which
explains the link with chromatine remodelling. As EMSY does not possess
such a domain, it interacts with HP1b and BS69.
The median disease-specific survival for node-negative breast cancer was
6.4 years with EMSY amplification, but 14 years withoutref.
(20-30%) : mammary-specific expression of an activated ErbB2 allele leads
to the formation of mammary adenocarcinomas in mice. Despite levels of
ErbB2 expression in the mammary epithelium comparable to those of animals
with tissue-specific activation, mice carrying germline ErbB2 do
not develop tumours : feedback mechanisms during development compensate
for germline oncogene expressionref.
After preoperative chemotherapy, HER2 status may change from that detected
in the core biopsy specimen to that in a sample of the resected breast
cancer in 4-35% of cases as assessed by IHC and in 13% of cases as assessed
by fluorescence in situ hybridization (FISH)ref1,
ref2,
ref3,
ref4,
ref5.
HER2-negative status may convert to a positive status in 2 to 9%ref1,
ref2,
ref3
of patients, as assessed by IHC or FISH, and from a positive status to
a negative status in 15-26% of patients, as assessed by IHCref1,
ref2,
ref3
or in 4%, as assessed by FISHref
(15%)
(20-25%, well below its average of 50% in all types of cancer)
(< 10%, below its average of 25% in all types of cancer)
in healthy mammary glands and its loss in some breast cancers points to
a tumour suppressor role, which could have value in a diagnostic setting
(up-regulated thanks to positive selection exercted by hypoxia on tumour
cell clones lacking inhibition of the VHL tumour suppressor over HIF-1a)
and CCR7
and are characterized by a distinct metastatic pattern involving the regional
lymph nodes, bone marrow, lung and liver, ie tissues that express peak
levels of the ligand chemokines CXCL12
and CCL21
: signalling through CXCR4 or CCR7 mediates actin polymerization and pseudopodia
formation, and subsequently induces chemotactic and invasive responses.
of the lactiferous ducts
(a mutations seen also in congenital
mesoblastic nephroma
and congenital fibrosarcoma) results in constitutive activation
of wild-type NTRK3, which activates the Ras-MAPK and the PI(3)K pathways
for mitogenesis and cancer survival.
(2% of all invasive carcinomas)
(2% of all invasive carcinomas)
(1% of all invasive carcinomas)
can pick tumours that mammography would miss, such as DCIS, even if the
tissue is dense (as in younger females) or if the tumour is not calcified
: sensitivity = 76%, specificity = 88%detects
increased choline levels in malignant tissues.
in old females (fatty breast) : sensitivity = 36-90%, specificy = 95%.
Women with familial breast cancer are more susceptible to the mutagenic
effect of the low-dose irradiation used for a mammogram, so exposure to
X-rays should be kept to a minimum. No statistically significant differences
in detection rates were observed between the x-ray and full-field digital
mammography : anyway radiation for patients may be incrementally lower
with digital screening depending on the type of detector used. The overall
diagnostic accuracy of digital and film mammography as a means of screening
for breast cancer is similar, but digital mammography is more accurate
in women under the age of 50 years, women with radiographically dense breasts,
and premenopausal or perimenopausal womenref.
in young females (dense breast) differentiates between cystic and solid
nodules,
TK
and TPA
> CEA
(also CA125
for eventual association with ovarian tumors in patients with BRCA1 or
BRCA2
mutations)
for ovarian tumors in patients with BRCA1 or BRCA2
mutations
is a candidate markerthat may be useful for identification of breast lesions
that can develop into cancerref
confirmed by X-rays for osteolytic
bone metastases
for pulmonary
metastases
for liver metastases|
|
|
|
|
| 1 point |
|
|
|
| 2 points |
|
|
|
| 3 points |
|
|
|
(68%) only in clones overexpressing of IL-11
(which induces osteoclast formation), MMP1,
CXCR4,
osteopontin
(which stimulates osteoclast adhesion to the bone matrix), and CTGF,
usually occurring in association with widespread metastatic diseaseref1,
ref2.
The reported interval from the initial diagnosis to the development of
bladder metastases ranges from 7 months to 30 years, with a mean interval
of 7.5 yearsref.
Lobular carcinomas appear to have a stronger association with bladder metastases
than the more common ductal subtype of breast carcinomaref.
Lobular carcinomas have a propensity to metastasize to serosal surfaces,
the gynecologic tract, and the gastrointestinal tractref,
and perhaps spreading from these adjacent sites accounts for the greater
frequency of bladder involvement. Metastatic lobular carcinoma also often
occurs as a diffuse thickening of an affected organ, as seen in this case,
rather than as discrete tumor nodulesref.
The development of bladder metastases has generally been a poor prognostic
feature, and most patients die of the disease within 2 yearsref.
or BRCA2,
are, at present, offered prophylactic mastectomy
with eventual axillary lymphadenectomy
after positive sentinel lymph node (SLN)
detection : women whose tumours are removed in a particular phase of their
menstrual cycle are more likely to get metastases, but other studies have
found no such link
before surgery in patients with HER2
/ ERBB2+
breast
carcinomas : the release of TGF-a
and heparin-binding EGF
triggered by surgery (which directly relates with the amount of tissue
damage) causes the high level of recurrence, expecially in HER2
/ ERBB2+
carcinomas
+ axillary lymphadenectomy
+ eventually followed by adjuvant radiotherapy
(QUART)
(radical Meyer or
Halsted mastectomywhen
greater pectoral muscle is infiltrated)
(in T1 or T2 only when >= 4 axillary or >= 1 internal mammary lymph nodes
are involved; or when OncotypeDX® test is positive in tamoxifene-treated,
node-negative (based on 16 cancer genes and 5 noncancer genes, which can
identify 50% of patients who have an excellent prognosis and most likely
don't need chemotherapy)ref).
and opposed field (medial and lateral, both tangential to chest) irradiation
(CT planning with isodose curves allows maximal sparing of heart, lungs,
skin and subcutis). Radiotherapeutical burst (+ 10 Gy) over surgery scar.
Also electron bundles and high-dose rate (HDR) interstitial
brachytherapy
(worse aesthetic results) are used, while intraoperatory radiotherapy is
under study.
for control of osteolytic
bone metastases
: delay radiotherapy as CMF induces cells to enter G0, the least
radiosensitive cell cycle stage
: radiotherapy may be started simultaneously
and gemcitabine
for BRCA1 and BRCA2 mutations
is effective in the control of hot flashes at a dose of 900 mg/dayref
for 2 years
antagonists (tamoxifen)
for 5 years : > 50% have or develop resistance via ...-independent)
pathway for cell growth and proliferation, leading to activation of GPR30
and release of heparan sulfate-bound EGF.
inhibitors (e.g. letrozoleref)
in post-menopausal women, defined as follows:
activation
in ErbB2+ tumors (15-25%) : adjuvant treatment with docetaxel,
as compared with vinorelbine, improves recurrence-free survival in women
with early breast cancer. A short course of trastuzumab administered concomitantly
with docetaxel or vinorelbine is effective in women with breast cancer
who have an amplified HER2/neu generef
values >11/µL were associated with a longer PFS and an improved OS
in patients with advanced breast cancers receiving metronomic chemotherapy.
Preclinical models indicated that the source of apoptotic CEC was most
likely the tumor vasculatureref
(SIR = 1.35), colorectal
(SIR = 1.22; another study found no increased riskref),
lung
(SIR = 1.24), soft tissue sarcoma
(SIR = 2.25), melanoma
(SIR = 1.29), non-melanoma
skin
(SIR = 1.58), endometrium
(SIR = 1.52), ovary (SIR = 1.48), kidney
(SIR = 1.27), thyroid
gland
(SIR = 1.62) and leukaemia
(SIR = 1.52). The excess of cancer after a breast cancer diagnosis is likely
to be explained by treatment for breast cancer and by shared genetic or
environmental risk factors, although the general excess of cancer suggests
that there may be additional explanations such as increased surveillance
and general cancer susceptibilityref.| Breast cancer news
|
is used in elderly females, when fatty tissue has replaced glandular tissue
=> FNAB
and cytology.
in young females, when the high glandular content prevents discrimination
of calcifications.is
used only when sero-hematic secretions (not galactorrhea) suggest ductal
tumors
with blood pool contrast agents
is practiced aunder mammographic guidance (which shows calcifications);
ABBI®, Fisher®, Imagyn® and
Mammotome®
(source : Ethicon Endo-Surgery, Inc.) are guide systems for vacuum-assisted
excisional
biopsy
that leave in situ a guidance thread (a radiography of the ablated
tissue is practiced as confirmation of a good surgery). Digital imaging
enables a physician to use the computer-guided probe to gently collect
tissue samples through one small 1/4 inch incision : a breast biopsy can
be performed in an outpatient setting under local anesthesia. 80% of breast
biopsies do not turn out to be breast cancer
and diseases
of endocrine ovaries)ref
(oophoritis parotidea)
+ hCG
(10% of all ART
cycles); life-threatening in 0.5-2%
|
|
|
| age < 35 years | age > 35 years |
| PCOS (type II OHSS) | hypogonadism (type I OHSS) |
| asthenic habitus | overweight |
| estradiol > 4,000 pg/mL | estradiol < 4,000 pg/mL |
| mature follicles > 35 | mature follicles < 20 |
| pregnancy | no pregnancy |
| luteal support with hCG | luteal support with progesterone |
| GnRH-a-including protocol | GnRH-a-less protocol |
|
|
|
|
|
| ovarian enlargement | 5-12 cm | > 12 cm | variable |
| abdominal tension | moderate | severe | abdominal reaction |
| ascites |
no | yes | massive |
| pleural
effusion |
no | possible | yes |
| pericardial
effusion |
no | not frequent | not frequent |
| renal failure |
no | not frequent | frequent |
| thromboembolism |
no | no | possible |
| ARDS |
no | no | possible |
| hemoconcentration |
HCT < 45% | HCT > 45% | HCT > 55 |
| WBC/mL | < 15,000 | > 15,000 | > 25,000 |
| liver enzymes | normal | high | high |
| creatinine (ng/mL) | < 1.0 | 1.0-1.5 | > 1.6 |
| CLcreatinine | > 100 | 50-100 | < 50 |
if ovarian transvaginal echography
(TVE)
shows > 5 follicles
for 4-6 cycles, laparotomic ablation if > 5-6 cm (enucleation in reproductive
age)
incretion or nonfunctional
on hypothalamic GnRH incretion
or rarely torsion around peduncle
stimulation in 30% of trophoblast cancers
(10-15 cm in diameter; persisting after removal of the mole)
and diabetes mellitus
administration to induce ovulation and pregnancy
incretion
: lack of follicular stigma over ovary and low [progesterone]peritoneal
fluid
)
(70%), BRCA2
(10%) have predictive value of 40%.
(amplified in 17% of ovarian cancers)
may substantially reduce the risk of ovarian cancer by age 70 years in
women with a family history of the disease, from approximately 4% to only
2%ref,
with protective lasting up to 10 years after cessation
affords a risk reduction even 20 or more years after the surgery).
,
OPCML
LOH. Sphingosylphosphorylcholine
(SPC)
is found at increased concentrations in the blood and malignant ascites
of patients and reorganizes kerating filaments, which increases the elasticity
of cells and therefore aids their migration during metastasis.
(50% mortality)
+
in 94%. Complex papillary projections into the cystic lumina; associated
with tubal epithelial hyperplasia. Peritoneal implants in 33% of cases
(adenomyosis tubae / endosalpingiosis)
due to either metastases or synchronous coelomic metaplasia+
in 100%. Stage I in 77%. Average age at diagnosis : 34 years. Associated
with endometriosis in 30%. Prognosis is poorer than for the intestinal
type+
in 0%. Diagnosed at stage I in 77%, average age = 52 years.
and CA19-9]plasma
(for both serous and mucinous tumors) and [CEA]plasma
for mucinos tumors
,
still residuating after successful chemotherapy), many cavities, solid
lardaceous areas, and fragile vegetations on the external surface. Bilateral
in 50%(<
5% of the total in Western countries and 20% in Japan. In females younger
than 20, they represent approximately two-thirds of malignant ovarian tumors),
Morris'
syndrome
/ benign cystic, cystic, or mature teratoma and dermoid (98%) : a benign
teratoma
of the ovary, usually found in young women, presumably derived from the
ectodermal differentiation of totipotential cells, lined by apparent skin
and its associated adnexal structures, and typically filled with a sebaceous
caseous material in which is found hair. Pure sebaceous neoplasms arising
in dermoid cysts of the ovary are exceedingly rare.
(45%)
(12%) (Teilum tumor : Teilum G. Classification of endodermal sinus
tumor (mesoblastoma vitellinum) and so-called "embryonal carcinoma" of
the ovary. Acta Pathol.Microbiol.Scand. 64:407-427 (1965))
(5%)),
hematogenous spreading to lungs and liver and later to brain and bones.
The size of tumors varies from 7 cm to 40 cm with a median of 15-16 cm.
The tumor is rarely bilateral (5-19% : 10-15% in dysgerminoma) and never
so in cases of endodermal sinus tumor.
(median
longitudinal incision to explore whole abdominal cavity and, in
dysgerminoma,
retroperitoneum), aspiration of ascitis or multiple peritoneal washings,
selective biopsy, ipsilateral lumboaortic and pelvic lymhadenectomy for
dysgerminoma
(biopsy of contralateral ovary may cause adherence and impair future fertility
preserved by conservative surgery). Single cyst enucleation in bilateral
neoplasia; bilateral ovarosalpingectomy for gonadal dysgenesis (risk factor
for ex novo transformation). Bilateral adnexectomy only in postmenopausal
females.
or VBP.
The VBP regimen seems to have a stronger cancerocidal effect, while the
VAC regimen is less toxic. VAC produces excellent results in stage I, while
VBP is more effective for advanced disease. Conservative surgery and a
combination chemotherapy (VAC, VBP) are appropriate for young patients
who desire to retain their fertility.
for 3-5 cycles in initial stages or 5-9 cycles in late stages. Menstruations
reappear within 6 months after cessation
(very sensitive to radiation)
or mixed type tumor have a poorer outcome. The survival rate is higher
in patients with earlier disease (stage I or II) and those who underwent
primary surgery. Metastasis to the lymph node is not related to prognosis.
The presence and size of residual tumors after surgery are closely related
to the prognosis.
and have a tendency to cystic degeneration. The tumor is rarely composed
entirely of theca cells (thecoma); commonly both theca and follicular
cells (granulosa cells) are found| adult type, frequently associated with cystic or adenomatous glandular endometrial hyperplasia or well differentiated endometrial adenocarcinoma (5%) or breast tumors | juvenile type, frequently associated with early pseudopuberty, accelerated somatic and skeletal development, menarche and leukorrhea | |
| incidence | 95% | 5% |
| age | 42-53 (75%) | prepuberal (2-4%), < 30 (15-20 |
| stage | Ia in 80% | Ia in 90% |
| bilaterality | 4% | inusual |
| follicular histology | small (Call-Exner bodies) | large, irregular |
| cytoplasm | small | abundant |
| nuclei | pale | hyperchromic |
| mitoses | variable | many |
| relapse | late | early |
| course of relapse | slow | fast |
]plasma;
coffee-bean nuclei
,
although occasionally estrogenic activity results,
inducing endometrial hyperplasia
with menorrhagia. Juvenile granulosa cell
tumour is rare and can be associated with galactorrhearef
,
infiltration, .... (70%), carcinous nodules, dysuria, dyschezia, female
dyspareunia, intolerance to meat, ascites,
fatigue, nausea and vomiting, abdominal cramping, diarrhea, epigastric
disorders, anorexia, slimming, cachexia, dyspnea
due to pleural
effusion
(5%), supraclavear lymphadenopathy, palpable nodules at digital vaginal
and rectal explorations
(with echo-color doppler
(ECD)
that detects anarchic vascularization, different from ovulation and luteogenesis,
or PID and ectopic pregnancy. Peripheral
vascularization in functional and benign cysts, central and septal vascularization
in malignant tumors. Lack of protodiastolic notch suggests neoangiogenesis
: lack of muscular coat in neoformed vessels allow a low-resistance blood
flow; pulsatility index < 1.0 and resistance index < 0.4)]plasma
> 35 U/mL (sensitivity = 52-83% (50% in stage I, 90% in stage III or IV);
specificity = 90%)
+ CA125]plasma
(sensitivity = 95%; increased in 80% of nonmucinous cancers)]plasma
(sensitivity = 83%)
+ CA125]plasma
(sensitivity = 74-94%),
prolactin,
osteopontin and IGF-2identify
cancer with 95% accuracy in a test group of > 200 women. The test would
now have to be improved before it is good enough for national screening,
which requires an accuracy of at least 99.6%
(difficult to perform, risk of peritoneal carcinomatosis and peritonitis
=> ascitis)
or laparoscopy
(often without established diagnosis) : < 20% of patients have cancer.
Practice peritoneal washing if peritoneal exudate is lacking. Inspection
and palpation of pelvis and abdominal viscera avoiding rupture of tumour
capsule.
and MRI
of abdomen and pelvis only for staging
analysis of blood samples to identify patients with ovarian cancerref1,
ref2,
ref3.
Laser capture microdissection microscope (LCMM) allows the isolation of
pure normal cells, pre-cancerous cells, and tumor cells biopsied from the
same patient (before and after treatment)
(abdominal fluid build-up) or peritoneal lavage ("washings" from the abdominal
cavity).
or peritoneal lavage.
or peritoneal lavage.
or peritoneal lavage; pelvic extension (pelvis includes the true or minor
or small as well as the false major or large or false pelvis).
or peritoneal lavage.
or peritoneal lavage.
: lumboaortic =>),
(2-3%; intraparenchymal, not on glissonian capsule !), pulmonary metastases,
cutaneous metastases, brain metastases, osteolytic
bone metastases
present containing malignant cells. No tumor on the external surface; capsule
intact
present containing malignant cells. No tumor on the external surfaces;
capsules intact
present containing malignant cells, or with positive peritoneal washings
present containing malignant cells or with positive peritoneal washings
equals Stage III. Tumor is limited to the true pelvis, but with histologically
proven malignant extension to small bowel or omentum
is present, there must be positive cytology to allot a case to Stage IV
(differential diagnosis with paraneoplastic pleural effusion). Parenchymal
liver metastasis equals Stage IV
+ paclitaxel
+ cisplatin,
intravenous paclitaxel
+ intraperitoneal cisplatin and paclitaxel improves survival in patients
with optimally debulked stage III ovarian cancerref
=> adjuvant chemotherapy
and gemcitabine
> topotecan
(response rate = 30-35%)
is used only in treatment of pelvic relapses and in palliative therapy
and the hereditary non-polyposis
colorectal cancer (HNPCC)ref
(chosen by 89% of affected US females : anyway ectopic remnants may still
give rise to tumors !)
+ [CA125]plasma
+ pelvic examination 2 times a year after age 25| FIGO stage |
|
| Ia |
|
| Ib |
|
| Ic |
|
| IIa |
|
| IIb |
|
| IIc |
|
| IIIa |
|
| IIIb |
|
| IIIc |
|
| IV |
|
| grade |
|
| G1 |
|
| G2 |
|
| G3 |
|
|
|
|
| G1 |
|
| G2 |
|
| G3 |
|
|
|
|
| complete pathological remission |
|
| microscopic residue |
|
| residual disease < 2 cm |
|
| residual disease > 2 cm |
|
|
|
|
| mucinous |
|
| endometrioid |
|
| clear cell |
|
| serous |
|
| undifferentiated |
|
of
the stomach
(advanced
gastric cancer (AGC))
or of
large bowel.
Once considered transcoelomatic (gravity) metastases, it has been shown
to arise from retrograde lymphogenous metastases. The metastatic nature
was not recognized by Krukenberg : it was Schlaggenhaufr who recognized
it. This term should no longer be used in oncology. (Krukenberg F. Uber
das fibrosarcoma ovarii muco-celulare carcinomatodes. Archiv f.Gynecol.
50:287 (1896))
with ascites
and benign ovarian tumor, both of which resolve on removal of the tumorref
and/or ascites
secondary to ovarian neoplasms other than benign primary tumors
with full bladder (to rise womb)
: preantral => antral follicles (2-4 mm)
and increased estradiol => all follicles but the dominant one (20-21 mm)
undergo atresia
surge : lack of dominant follicle and sudden volume reduction, fluid in
Douglas' cavity (40%),
which is caused by abuse of anthracene-containing laxatives. Residual bodies
of mucosal cells, macrophages and endothelial cells of the lamina propria
contain iron-containing particles (cytoplasmatic ferritin and hemosiderin
in siderosomes) and lipofuscin. The origin of the excess iron is not clear,
but erythrophagocytosis and an abnormal tubal environment could play a
role. Iron-promoted lipid peroxidation may alter the lysosomal membranes
and contribute to the excessive accumulation of lipofuscin in these cellsref1,ref2.
The condition may be due to cellular damage caused by pelvic radiotherapy
or idiopathic and may lead to complete tubal stenosis and mechanical
sterility.
100 mg 2 times a day for 14 days + ceftriaxone
250 mg i.m.
tumor of the broad ligament)
(severe dysmenorrhea). Rarely atresia is complete and no blood collects
during menstruations.
diseases
diseases.,
with the presence of tubercles; usually the uterine tubes are also involved.
of the endometriumref
or pathologically before menopause and accompanied by absence of menstrual
flow and shrinkage of the uterus.
of the uterus, characterized by the development of multiple, sharply circumscribed,
unencapsulated (pseudocapsule), gray-white tumors (color according to prevalence
of muscular or fibrous components, the latter increasing with age), which
are firm, usually round, and show a whorled pattern on cut section. They
are localized within the myometrium of the :,
marked by the formation of soft red areas due to necrosis and edema.-induced
hyperestrogenism and GH
(or human
placental lactogen (hPL) / human chorionic somatomammotropin (hCS)1
during pregnancy) (fibromatous uterus) : endometrium may undergo ischemic
atrophy and necrosis in submucosal leiomyomas
or ectopic EPO
incretion => polycythemia; late menopause. Tend to enlarge during pregnancy.
may increase volume; on the other side IUDs may dislocate)
from menstrual day 5-10 up to day 24-25 + tranexamic
acid
against menorrhage
if < 5 cm in diameter
or radical hysterectomy
in perimenopausal females
impairing catabolization of adrenal D4-androgens,
which can then be converted into estrogens by fatty tissue
: hyperinsulinemia and high levels of IGF-1 => endometrial proliferation
: progestins assumed for 3 weeks per month (contrary to normal 2 weeks
per month duration of luteal phase). -51% RR after 4 years, -70% RR after
10 years, persisting for about 15 years.
+ progestins > 10 days per month mildly reduces the risk
to measure thickness of endometrium,
in which the glands vary in size and shape, producing an appearance like
that of Swiss cheese, with its large and small holes
with bilateral adnexectomy
10 mg/day since menstrual day 10 to 24
25 mg/day since menstrual day 16 to 25
20 mg/day since menstrual day 10 to 24
5 mg/day since menstrual day 10 to 24
200 mg/day for 60 days
+ ethynyl estradiol (EE)
150 mg + 30 mg for
21 days, for 3-6 cycles
+ ethynyl estradiol (EE)
75 mg + 30 mg for
21 days, for 3-6 cycles
with those who didn't drink alcohol. Half of the monkeys were trained to
voluntarily consume 2 drinks of alcohol every weekday for 26 months. There
was no difference in the cancer markers between the 2 groups. The results
might not apply to women who undergo hormone therapy, or to premenopausal
women : alcohol may increase estrogen levels in women whose bodies still
produce estrogen and increased levels of estrogen are associated with higher
risk of breast cancer.
reduce incidence by 50%
(60-70%) : tumor cells differentiated into nonsecreting glandular tissue
with little or no stroma (desmoplastic instead of normal cytogenous)| TNM (Fédération Internationale de Gynécologie-Obstétrique (FIGO)) staging |
|
||
| I : < 5% of a non-squamous solid growth pattern (lumen-less glands) | II : 6-50% of a non-squamous solid growth pattern | III : > 50% of a non-squamous solid growth pattern | |
| Tis (0) | |||
| T1 (I) : within corpus => draining to paraaortic lymph nodes
|
|
|
|
| T2 (II) (invades cervix => draining also to pelvic lymph ndoes)
|
|
|
|
| T3
T4 (IVA) : tumor invades bladder mucosa and/or bowel mucosa |
|
|
|
(2-3%), bone metastases, liver
metastases
: benign squamous cells. Prognosis as for pure endometrioid endometrial
carcinoma
(15-20%) : malignant squamous cells, worse prognosis.
(< 10%) : average onset at age 66, no hyperestrogenism, abdominal relapses;
5-yr OS = 45% in stages I and II; psammoma
bodies
(33%) and surrounding atrophic epithelium (75%); metachronous neoplasms
on ovarian germinal epithelium or peritoneum (field effect). Its precursor
is endometrial intraepithelial carcinoma (EIC) / endometrial carcinoma
in
situ (ECIS)
: endocervical differentiation, but better prognosis than primary cervical
adenocarcinoma
(false positives in females treated with tamoxifen)
is useless as desquamated cells from uterine corpus are too necrotic to
allow histological diagnosis,
CYFRA
21-1]plasma
and bilateral adnexectomy (ovariectomy)
and upper third colpectomy, peritoneal washing, selective pelvic (periaortic,
common iliac, external iliac and obturator) and lumboaortic lymphadenectomy
+ adjuvant external beam radiotherapy
(EBRT)
(45-50 Gy) in patients with undifferentiated neoplasm, deep myometrial
infiltration (T1c) or extension of neoplasm over lower segment of uterine
and bilateral ovariectomy
with adjuvant external beam
radiotherapy (EBRT)
(45-50 Gy)
(50-60 Gy : external beam radiotherapy
(EBRT)
and endouterine intracavitary
brachytherapy
or low-dose rate (LDR) interstitial
brachytherapy)
+/- adnexectomy
+ adjuvant radiotherapy
(45-50 Gy : external beam radiotherapy
(EBRT)
and endovaginal intracavitary
brachytherapy)
in T1c
+ omentectomy
+ selective lymphadenectomy
+ abdominal and pelvic adjuvant radiotherapy
(45-50 Gy : external beam radiotherapy
(EBRT)
and intracavitary
brachytherapy).
Eventually adjuvant chemotherapy with doxorubicin
+ cisplatin
(45-50 Gy)+
and PR+
cancers : medroxyprogesterone
acetate (MPA)
200-1,000 mg/die p.o., megesterol
acetate
160 mg/die p.o., tamoxifen20-40
mg/die p.o.)
(50-60 Gy : external beam radiotherapy
(EBRT)
and intracavitary
brachytherapy)
(50-60 Gy) for menometrorrhage or pain due to pelvic and/or bone infiltration,
radiation
colitis,
radiation
cystitis,
vaginal and rectal tenesmus, rarely adherences
in women with the hereditary non-polyposis
colorectal cancer (HNPCC)ref
expression (targets for antiestrogen chemotherapy), 5-year OS = 65% (from
80% for stage I patients to > 10% for stage IV patients); overall mortality
= 1%.
tumor of the uterine corpus
diseases
administration during pregnancy prevents metaplasia of the ectopic glandular
epithelium arising from mullerian ducts in the embryo
ref
(asymptomatic in 50%; leukorrhea and dypareunia,
sometimes recurrent burning at urination)
100 mg 2 times a day for 7 days, azithromycin
2 g in monodose, erythromycin
500 mg 4 times a day for 7 days, ofloxacin
300 mg 2 times a day for 7 days
of the uterine cervix
(90%) on an area of cervical squamous
metaplasia
inducing its degradation
in women who are HPV+
when involving endocervix : the removal of a cone of tissue (2-cm base
in ectocervix and 2.5-cm height along cervical canal)
with no lymphadenectomy due to low lymph node involvement (< 4%)(more
aggressive)
=> dysuria, stranguria or hematuria
=> massive hemorrhage => anemia; tenesmus, proctorrhage
or pelviperitonitis
; ureteral infiltration leads to gravative pain to flank and obstructive
uropathy => hydronephrosis
=> relapsing cystopyelitis, pyelonephritis, sepsis or postrenal
acute renal failure
if bilateral => uremic coma; pain and swelling to lowe limb due to obstruction
of pelvic lymphatics
: finely granuled, exophytic => ulcerated look; biopsy
and rectosigmoidoscopy
+ pelvic lymphadenectomy
(including adnexectomy) + pelvic lymphadenectomy
(+ adjuvant external beam radiotherapy
(EBRT)
when N>=1, pericervical microscopic invasion, cervical size > 4 cm, neoplastic
emboli in lymph or blood vessels of parametria) if controindications to
radiotherapy exist (PID, UC, sigma diverticulosis). Ovariectomy is of doubtful
utility : squamous cell carcinoma spreads to ovary in 0.5% of initial stages
and 15% of advanced stages, while cervical adenocarcinoma spreads to ovary
in 8% of initial stages and 30% of advanced stages.
to treat the parametria and pelvic nodes (< 2 cm : 40-50 Gy; bulky :
> 60 Gy) + intracavitary
brachytherapy
to treat the primary tumor
(effective only in 60%) + chemotherapy (cisplatin
+ 5-fluorouracil (5-FU)
+ hydroxyurea)
+ 5-fluorouracil (5-FU)
+ ifosfamide;
vincristine)
+ palliative intracavitary
brachytherapy
(untractable hemorrhages, pain, bone metastases, brain metastases)
tumour marker)(5-10%)
within cervical canal (no vegetations in vaginal lumen, worse prognosis),
and ST3.
L1CAM
expression marks poor prognosis.
of ectocervix, vagina and cervical canal all together on 3 different glasses,
during ovulatory stage (when cervical mucus is more fluid columnar endocervical
cells are exfoliated; not during menstruation), fixed with alcohol-ether
spray allows detection of koilocytes and desquamated atypical cells (whose
number directly relates with CIN grade) and is used in screenings)
infections,
CYFRA
21-1.
(eventually echo-color
doppler (ECD))
shows the myometrium as hypoechogenic and the endometrium as hyperechogenic
for ureteral stenosis
for mechanical infertility : impaired oocyte descent or embryo implant.
It assesses).,
Chlamydia
trachomatis,
Escherichia
coli,
Mycoplasma
hominis)
from intestinal or urinary tract, intense sexual activity, IUDs,
clandestine abortion
,
ie. :
(sensitivity = 95%) with peritoneal fluid sampling and differential diagnosis
(McBurney's test, nausea, vomiting and meteorism), acute
cholecystitis
(epigastric pain radiated posteriorly on right flank), acute
pancreatitis(serum
amylase), urinary
tract infections
(pain at pressure on anterior fornix), pyelitis (only in patients with
renal ptosis or pelvic kidney), luteal hemorrhage, ectopic
pregnancy (monolateral pain and pregnancy signs), torsion of ovarian
cyst (lack of pain at pressure over contralateral fornix)
(900 g i.v. 3 times a day) + gentamycin
(i.v. 2 mg/kg followed by maintenance with 1.5 mg/kg every 8 hrs)
(100 mg capsules p.. 2 times a day) + cefoxitin
(2 g i.v. 4 times a day)
(250 mg i.m.) or cefoxitin
(400 mg p.o.) + doxycyclin
(100 mg 2 times a day for 3 weeks)
(200 mg capsules) + metronidazole
(2 250 mg capsules 4 times a day for 14 days)
(4 capsules a day) or Serratiapeptidase
(3 capsules a day)))
/ vaginosis
administration during pregnancy (in cases of premature
delivery, preeclampsia
or complications of diabetic pregnant) prevents the squamous metaplasia
(induced by the postpubertal acidic vaginal environment) of the ectopic
glandular epithelium arising from mullerian ducts in the embryo
)
inflammation of the vagina
is found also in 55% of asymptomatic females)
400-500 mg 2 times a day for 7 days or 2 g monodose) or clindamicyn
(in severe infections by anaerobes and gram-positive bacteria; contraindicated
in patients with IBDs and diarrhea)
+ clotrimazole
vaginal cream for 7 consecutive evenings
vaginal cream 2% for 7 consecutive evening
: colpitis macularis / strawberry cervix (punctate hemorrhage
of the vaginal mucosa, often with small vesicles or papules), rarely pseudomembranes,
rich in parabasal and intermediate cells (differential diagnosis with intraepithelial
VaIN), reversible in 1-3 months after therapy
and characterized by a thick creamy discharge, pruritus, and erythema
cyst or gartnerian cyst : a benign cystic vaginal tumor (rarely multiple)
developed from remnants of Gartner's duct, on the anterolateral area of
the fornix, < 4-5 cm in diameter,
rectocele
/ rectovaginal hernia,
dilated blunt-end supranumerary ureter (urography and cystography)
and colpocytology.
)
(>90%) from the posterior wall of the upper third of the vagina, synchronous
or metachronous with cervical
squamous cell carcinoma
(4-5%)
(3%) from junctional melanocytes in the anterior wall of the lower third
of the vagina
with eventual biopsy, gynaecological examination under general anaesthesia
is common, not least because affected women may have used many topical
agents on the vulva before presentation to a specialist clinicref
(Kaufman RH, Faro S. Benign diseases of the vulva and vagina. St Louis:
Mosby-Year Book, 1994). Irritants include soap, panty liners, synthetic
underwear, moistened wipes, deodorants, douches, lubricants, spermicides,
topical medication, urine, faeces, and excessive vaginal discharge. Allergic
contact dermatitis
also occurs, for example with prescribed topical medication or sanitary
napkinsref1,
ref2.
Candidiasis
can cause vulval burning and itching, and treatment has been reported to
improve the symptomsref.
Other causes include: vulvovaginal atrophy (oestrogen-deficient), recurrent
herpes simplex infection,
herpes
zoster and post-herpetic neuralgia,
lichen
sclerosus,
erosive
lichen planus,
Behçet's
syndrome,
cicatricial
pemphigoid,
Sjögren's
syndrome,
vulval
intraepithelial neoplasia, and carcinoma (Ridley CM, Neill SM,
eds. The vulva. Oxford: Blackwell Science, 1999; Kaufman RH, Faro
S. Benign diseases of the vulva and vagina. St Louis: Mosby-Year Book,
1994; Lynch P, Edwards L. Genital dermatology. Edinburgh: Churchill Livingstone,
1994)
if areas of cytological atypia are detected
(see also trichomonas vaginitis ;
prevalence = 5-35%; incubation = 48 hrs; sometimes extended to uterine
cervix; ferrous salts in menstrual discharges increase mutliplication and
increase symptoms; premature
rupture of membranes (PROM))
(vaginal thrush / vulvar candidiasis / Candida
vulvovaginitis / vulvovaginal candidiasis; see also Candida
vaginitis),
HIV, GR agonists,
systemic wide spectrum antibacterials, cytostatic, immunosuppressants,
spermicides or intimal detergents (replace with Marseilles soap), estroprogestins,
tight synthetic jeans or collant, IUDs, premenstrual stage. Female factors
associated with recurrence include recent masturbating with saliva or cunnilingus.
Male factors associated with recurrences in the woman included history
of the male masturbating with saliva in the previous month and lower age
at first intercourse. Sexual behaviors, rather than the presence of Candidaspecies
at various body locations of the male partner, are associated with recurrences
of C. albicans vulvovaginitisref1,
ref2.
vaginal cream 2% (1 application for 6 days)
(vaginal cream 1% or ovules 150 mg for 6 days or 2 depot vaginal ovules
150 mg monodose; 14 days for Candida
glabrata)
(vaginal cream 2% or ovules 200 mg for 6 days)
(vaginal cream 2% or ovules 100 mg for 7 days, capsules 400 mg for 3 days
or 2 capsules 1200 mg monodose)(vaginal
cream 1%, foam 2% or ovules 100 mg for 6 days)
(capsule 50, 100 or 150 mg in monodose)
(capsule 100 mg : 2 capsules 3 times a day)
(herpetic vulvovaginitis : mainly vulvitis; burning and pruritus, vesicles
or microulcerations, cervicitis (90%), pauciasymptomatic relapses every
10-15 days, inguinal lymphadenomegaly in primary infection; shorter duration
in recurrent infections (cervicitis only in 10-20%))
or p.o. capsule 200 mg 5 times a day for 10 days (2-3 times a day for >1
yr if > 6 relapses/yr) => famciclovir
or valganciclovir
5%but
microscopically representing a form of condyloma acuminatum, usually occurring
on the uncircumcised penis, but also seen elsewhere in the anogenital area
such as about the anus and vulva. It presents as a large verrucous to fungating,
cauliflower-like mass that erodes the involved skin and progresses to penetrate
and destroy the deeper tissues
and seborrheic
keratosis.
and
rIFN-an3
1,000,000 U/mL
0.5% (2 applications a day for 3 days : contraindicated in pregnancy (theratogen),
lactation and babies) : response rate = 50-60%; the histological changes
include :
5% (1/wk for 8-10 weeks) : response rate = 60-70%; side effects : symptomatic
erythema (30%), ulcers (10%), chemical dermatitis (1-2%)
(colpoxerosis)
cream,
broad-spectrum antimicrobials.
in females
in skin of vulva, perineum and perianus
associated or not to skin transplantation (complications : diastasis or
infection of surgical wounds; stenosis, urinary disorders, relapse, neoplastic
evolution, sexual disorders and psychological consequences)
deficiency,
Proteus
mirabilis,
Chlamydia
trachomatis,
Neisseria
gonorrhoeae,
or after.
for small cysts
to treat vaginal-perineal lacerations after delivery
to treat genital prolapse
cyst
cyst or hydrocele : the duct (similar to vaginal process of testis),
normally disappear at intrauterine month 4. Persistence may cause congenital
inguinal herniation or serous cyst (sometimes 2-3) in adults located in
the superior anterior region of labia majora, 2-5 cm in diameter, confused
for an oblique external inguinal herniation, but not reduceable nor expandable
under effort.
has been replaced by wait and see
still practiced in VIN III, wide lesions or diagnosed in postmenopausal
age
(2.2%) : like melanoma, even basal-cell carcinomas appear in sun-shielded
areas such as the vulva, challenging the conventional knowledge that associates
these cancers with ultraviolet radiation. Vulvar basal-cell carcinoma typically
includes poor pigmentation and, often, a clinical appearance that mimics
eczema or psoriasis. The dominant symptom, itching, often induces both
patients and doctors to dismiss the conditionref
(4.8%)
with bilateral inguinal and pelvic lymphadenectomy has been replaced by
tailor-made treatments. Inguinal-femoral lymphadenectomy is still required,
but may be ipsilateral if the cancer is small. Pelvic lymphadenectomy is
practiced only in patients with positive nodes, but postoperatory radiotherapy
has better outcome.
infection, in evaluating endocrine function, and in the diagnosis of malignancies
of other organs, as of the respiratory tract and lungs, gastrointestinal
tract, urinary tract, and breast)
administration to pregnant females :)
(see pelvic diaphragm
and urogenital diaphragm)
)),
sense of perineal weight, neoplasia protruding from external genitalia
(sometimes only in orthostasis or while coughing. Whereas some women with
prolapse have concomitant stress incontinence, others do not, in part because
of the obstructive effect of the prolapsed pelvic organs, creating urethral
kinking. When prolapse is treated with the use of a pessary or surgery,
stress incontinence may develop), female dyspareunia,
intermittent bleeding due to ulceration of extroflexed mucosa, strangling
of intestinal loops in the prolapsed vaginal cup
for prolapse, Burch colposuspension significantly reduced postoperative
symptoms of stress incontinence without increasing other lower urinary
tract symptomsref-sensitive
and begins to proliferate since menarca. Hemorrhages at menstruations cause
formation of small, red to black, painful (in perimenstrual phase) nodules/cysts
(2-4 mm), whose confluence generates endometriomas (chocolate cysts) :
the periodic increase in endocystic pressure may cause rupture and further
dissemination. Histological diagnosis is made when endometrial glands and/or
endometrial stroma and/or hemorrhages (RBCs, hemosiderin or hemosiderin-loaded
macrophages) are found. The surrounding inflammatory infiltrate and connectival
hypertrophy leads to tissue retraction. After menopause
it persists in obese women (due to high peripheral conversion of adrenal
androstenedione into estrone) and women undergoing HRT,
endometrial biopsy, uterine cervicoplasty
during therapy of prostatic carcinoma
(endometrium arise from mullerian remnants such as prostatic utricle and
appendix testis)
(1%)
or laparotomy practiced for other disease
surge
or low estrogen and progesterone
levels in peritoneal fluid (but normal in plasma)
in vesico-uterine septal and veical endometriosis
after rupture of a large endometrioma
or laparotomy including inspection of retroovarian pouches => biopsy and
histology (it can't see retroperitoneal localizations)]plasma
of stage III-IV endometriosis
or laparotomic lesionectomy and lysis of peritubal and periovarian synechiae)
for stage II and III endometriosis in fertile females => earlier pregnancies
(80% within 1 year; if not => laproscopic second look), attenuation of
symptoms (dysmenorrhea, deep female dyspareunia,
sacral and rectal pain), correcton of endometriosis-associated diseases
(uterine leiomyomas, uterine retroversion)
30 mg/day for 6-9 months or i.v. Depo-MAP 150-300 mg/wk for the first month
and then 150 mg/wk for 5-8 months). Side effects : intermittent metrorrhages,
reduction of HDLss
(21 days with 7 days interval)
2.5 mg 2-3 times a week for 6-8 months : it downregulates ER, binds to
SHBG, reduces hot-spots in 83%. Side effects : voice louding, hirsutism
and clitoris hypertrophy
400-800 mg/day since menstrual day 1 until amenorrhea, then 400-600 mg/day
for 6-9 months : it inhibits CYPs for steroidogenesis. Also a contraceptive,
a teratogen, and and immunodepressant (reducing risk of autoimmune abortion).
Clinical response rate : 70%; laparoscopicregression
in 80%. Side effects : weight gain, breast atrophy, ane, seborrhea, and
hirsutism, edema and fluid retention, headache, voice louding, heat rushes,
muscle cramps and tremors, acute porphyrias, insomnia, depression, alterations
of lipoproteins, increase of transaminases, CPK and LDH. Pregnancy rate
after cessation : 30-35%
for 6 months (reversible pharmacological hypophysectomy). Ovulation restarts
within 1-2 months. Side effects : atypical hemorrhages (25-81%), hot flushes
(19-100%), colpoxerosis (17-69%), decreased
libido (40%), mammary turgor (18-40%), insomnia (75%), depression (38-75%),
irritability and fatigue (19-25%), cutaneous dystrophias (13%). Pregnancy
rate 2-8 months after cessation : 10-57%.-associated
diseases (see also developmental
physiology,
reproductive
immunology,
and birth defects).
The past decade has seen a remarkable shift in the demographics of childbearing
in the United States. The number of first births per 1000 women 35 to 39
years of age increased by 36% between 1991 and 2001, and the rate among
women 40 to 44 years of age leaped by a remarkable 70%. In 2002, 263 births
were reported in women between 50 and 54 years of ageref.
and b2-ARs
in the oviduct muscularis implies that a basal endocannabinoid tone in
collaboration with adrenergic receptors coordinates oviductal motility
for normal journey of embryos into the uterusref.
incretion by ectopic trophoblast => decreased progesterone incretion =>
decidual necrosis => pelvic and/or abdominal pain (also due to hemorrhage)
=> lipothymia => small metrorrhages / spotting (70%) or tubal hemorrhage
=> hemoperitoneum,
Cullen's sign => hemorrhagic shock and peritonitis; pain at right shoulder
due to diaphragmatic irritation (10%), pain at palpation of posterior fornix
in retrouterine hematocele, embryo malformations (60%)
]plasma
lower than expected and 48-hr increases lower than expected (66%)
when [b-hCG]plasma
> 1,025 IU/mL and at abdominal echography when [b-hCG]plasma
> 6,500 IU/mL))
for irreversibly damaged tube, uncontroled hemorrhage after conservative
surgery or peritubal hematocele; ovariectomy
only when its vascularization is compomised)
or laparotomic10
mg for pregnancies with low or moderate trophoblastic activity after aspiration
of the gestational bag and monitoring of decreased [b-hCG]plasma
: after amniorrhexis, the presented part pushes over the placenta alllowing
hemostasis but also potentially causing acute fetal sufference
(riskful when placenta is inserted on the anterior wall of the lower uterine
segment) => tamponade of uterine cavity in post-partum to induce mechanical
hemostasis)
=> uteroplacental
apoplexy => loss of ability to retract after delivery => severe hemorrhages
after secundation
in uteroplacental
apoplexy)
(10%, due to sudden uterine distension, as in multiple
pregnancy,
polyhydramnios,
...), hyperthyroidism
(3-10%; due to high levels of chorionic TSH)
administration. > 90% has spontaneous remission. Strict follow-up has replaced
prophylactic adjuvant chemotherapy with methotrexate
)
or, rarely, are transported to distant sites, most often the lungs, vagina
(rarely liver and brain). It occurs mostly within 4-5 months after extraction
of a complete hydatiform
mole (rarely after partial hydatiform mole).
or proctorrhage
if infiltration of bladder or rectum occurs; symptoms & signs of pulmonary
metastases
shows sectorial alteration of uterine wall; loss of decrease of b-hCG
values,
cerebral,
liver metastases,
intestinal, renal or splenic metastases
for
pulmonary
metastases
(nodules 1-5 cm in diameter, ventriculomegaly and pulmonary artery dilatation)
with anti-b-hCG
mAb
/ MRI
plus rachicentesis ([b-hCG]serum/[b-hCG]CSF
< 60 suggests brain metastases)]serum
> 100 mg/mL (RIA) 21 days after removal, then every week until 3 serial
zeroing are achieved. If zeroing requires > 2 months, continue follow-up
for 6 months to exclude persisting trophoblastic disease. Then evaluation
every 6 months for partial mole or every 12 months for complete mole
> 100,000 IU/24-hour urine.|
|
|
|||
|
|
|
|
|
|
| age | < 39 | > 39 | ||
| antecedent pregnancy | hydatidiform mole | abortion | term | |
| interval between end of antecedent pregnancy and start of chemotherapy | <4 months | 4-6 months | 7-12 months | >12 months |
| [b-hCG]serum
[IU/L] |
<1000 | 1,000-10,000 | 10,000-100,000 | >100,000 |
| AB0 (female x male) | O x A or A x O | B or AB | ||
| largest tumor, including uterine | 3-5 cm | >5 cm | ||
| site of metastases | spleen, kidney | gastrointestinal tract or liver | brain | |
| number of metastases identified | 1-4 | 4-8 | >8 | |
| prior chemotherapy | single drug | two or more drugs | ||
]serum
> 20,000 UI/L after 4 weeks, persisting metrorrhage with plateau of [b-hCG]serum
, [b-hCG]serum
increasing in 3 consecutive examinations, histological diagnosis of choriocarcinoma,
dosable [b-hCG]serum
> 4-6 months after emptying, metastases)
50 mg at day 1, 3, 5, and 7 and folic acid 6 mg 30 hours after first administration
100 m2BSA (bolus) + 200 mg/m2BSA
i.v. in 12 hrs
)
and fetal
pulmonary maturation
(expecially at wk 30-33)
and daily CTG
to prevent amnionitis
volume (AFV)
or agenesis (urine is the main component of amniotic fluid), ARPKD
or multicystic
kidney disease
(33-57%), ureteral obstruction