2016, Vol 14, No 4
Differential relationship between two hypoxia markers: HIF-1α and GLUT1 and classic prognostic factors in invasive breast carcinoma
Curr Gynecol Oncol 2016, 14 (4), p. 197–203
DOI: 10.15557/CGO.2016.0024

Background: Tumor hypoxia is an adverse prognostic factor which promotes cancer aggressiveness and limits its radio- and chemosensitivity. The aim of our study was to explore the relationship between endogenous hypoxia markers and classic prognostic factors, including clinical stage and the expression of ER, PR, and HER2 in primary untreated breast carcinoma. Methods: A retrospective immunohistochemical analysis of archived tissue blocks collected from 153 women, who underwent total mastectomy and lymph node dissection, included the expression of two hypoxia-related proteins: HIF-1α and GLUT1. Results: GLUT1 labelling index (LI) showed a positive correlation with T stage (R = 0.18, p = 0.026) and HER2 status (R = 0.25, p = 0.002), and a negative correlation with the expression of ER (R = −0.19, p = 0.017) and PR (R = −0.17, p = 0.032). HIF-1α LI showed a positive correlation with ER expression (R = 0.16, p = 0.045). In the multivariate regression analysis, a different relationship between classic prognostic factors and the two tested hypoxia proteins was proven. Higher GLUT1 expression correlated with ER and PR negativity (p = 0.02 and p = 0.01, respectively) as well as with higher expression of HER2 (p = 0.04). HIF-1α showed no association with PR and HER2, but a positive correlation with ER (p = 0.02). Neither of the hypoxia proteins was associated with a tumor grade. Only one clinical feature, T stage, correlated with both of the hypoxia markers: positively with GLUT1 (p = 0.049) and negatively with HIF-1α (p = 0.01) expression. Conclusions: In breast cancer, GLUT1 expression may be considered an additional prognostic factor which correlates with an adverse status of HER2 and hormonal receptors, and indicates a more hypoxic, radio- and chemotherapy refractory profile of carcinoma.

Keywords: hypoxia, HIF-1α, GLUT1, prognostic factors, immunohistochemistry
Malignancies arising in mature teratomas of the ovary
Curr Gynecol Oncol 2016, 14 (4), p. 204–211
DOI: 10.15557/CGO.2016.0025

Mature teratomas are common ovarian tumors. Malignant transformation of dermoid cysts is a very rare phenomenon observed in only 0.17–2% of patients. Squamous cell carcinoma is the most common form of malignant transformation within ovarian dermoid tumors, accounting for more than 80% of cases. Adenocarcinomas, fibrosarcomas, carcinoid and mixed tumors also occur. Peritoneal gliomatosis is a rare condition, which also should be considered in patients diagnosed with teratoma. There are no sensitive and specific methods for the preoperative differential diagnosis of malignant vs. benign tumors arising in teratomas. Higher risk of malignancy is seen in large tumors, in women over 45 years of age, at elevated tumor markers (CA-125, CA 19-9, CEA, SCC-Ag in particular) and in the case of the presence of solid fragments in cysts. Extended diagnostic imaging using magnetic resonance or positron emission tomography is helpful in such cases. The treatment of mature teratoma, regardless of whether there is a suspicion of focal malignancy, involves surgical excision of the tumor. In the case of suspected malignant transformation in a perimenopausal woman, unilateral salpingooophorectomy in accordance with the principles of oncological aseptics should be considered as the minimum therapeutic management. Sparing surgery can be considered in young patients, nulliparas in particular, due to the very low risk of malignant transformations.

Keywords: ovarian teratoma, ovarian cancer, neoplastic transformation
The role of neoadjuvant chemotherapy in the management of advanced ovarian cancer in geriatric patients
Curr Gynecol Oncol 2016, 14 (4), p. 212–221
DOI: 10.15557/CGO.2016.0026

It is increasingly common for ovarian cancer to affect older women, with over half of all cases involving patients aged 65 years and older. Unfortunately, elderly patients with ovarian malignancy tend to be treated less aggressively than younger patients, with less extensive surgery and less intensive chemotherapy regimens. This is due to a variety of factors, such as overall medical fitness and the function of specific organs. Moreover, multiple morbidities are typical for geriatric patients and affect their eligibility for certain forms of cancer therapy as well as their treatment outcomes, which are commonly less satisfactory than in younger patients. Additionally, for fear of complications, treating physicians sometimes limit the extent of the necessary surgery, or adjust chemotherapy doses, even though such a course of management tends to be largely misguided. One available management option is neoadjuvant chemotherapy followed by a surgical treatment known as interval debulking surgery. This type of combination therapy is associated with fewer postoperative complications, thus increasing the patient’s chances of receiving a full course of adjuvant treatment. The decision to begin treatment with neoadjuvant chemotherapy tends to restrict later surgical therapy; however, under certain circumstances, this therapy can be a valid therapeutic option and, in fact, facilitate surgery. Prior to initiating therapy in elderly patients, their eligibility for combination therapy must be evaluated and the geriatric assessment of their performance and condition must be considered during the course of interdisciplinary preoperative management.

Keywords: ovarian cancer, neoadjuvant chemotherapy, primary cytoreductive surgery, geriatric patients, geriatric oncology
Possibilities of using radiotherapy in the treatment of vaginal recurrence in patients with uterine cancers
Curr Gynecol Oncol 2016, 14 (4), p. 222–230
DOI: 10.15557/CGO.2016.0027

A major problem in cancer treatment is disease recurrence, i.e. a situation in which the standard procedures turned out to be ineffective and the previously used therapy significantly limits its next use. Vaginal recurrence is found in 2.4–15% of patients with uterine cancer. For large recurrent tumors radical treatment involves surgical pelvic exenteration. However, indications for this procedure are significantly limited; in addition, it is associated with a high risk of complications and a significantly compromised quality of life. For this reason, brachytherapy and/or another course of radiotherapy are administered, which until recently were used as a further-line treatment option or as palliative care. Over the last few years extension of indications for radiotherapy and brachytherapy has been noted due to the dynamic development of new techniques for planning and conducting treatment. These allow for the irradiation of the target volume which causes radiation-related reactions that are acceptable for the patient while protecting critical organs. The introduction of new therapeutic devices allowed for the use of different treatment techniques, including intensity-modulated radiation therapy, image-guided radiotherapy, RapidArc, tomotherapy, intraoperative radiotherapy and stereotactic body radiotherapy, which contributed to a significant increase in the role of repeat radiotherapy. One needs to remember about the possibilities of systemic treatment, although it is usually palliative in nature. Brachytherapy may be considered for the treatment of recurrent disease if the lesions are located in the region of the vagina or vaginal stump or if infiltration is found in the parametria; in other situations treatment combined with external beam radiotherapy should always be considered. The choice of brachytherapy method depends on the location of the lesion and the extent of infiltration. If the infiltration is up to 5 mm deep, intracavitary brachytherapy is performed. If the infiltration is deeper, the use of interstitial brachytherapy is indicated.

Keywords: vaginal stump, recurrence, radiotherapy, brachytherapy
Hysteroscopy in fertility-sparing treatment in cases of atypical hyperplasia and early endometrial cancer – benefits and risks
Curr Gynecol Oncol 2016, 14 (4), p. 231–236
DOI: 10.15557/CGO.2016.0028

Hysteroscopy represents a method of uterine cavity visualization, used as both a diagnostic and also a therapeutic procedure. Hysteroscopy enables diagnosis of infertility causes (uterine defects, adhesions, changes in the uterine ostium of the oviducts), precise removal of abnormal endometrium, uterine polyps, submucosal myomas and ablation or resection of pathological endometrium. Hysteroscopy or curettage of the uterine cavity are used in diagnosis and fertility-sparing therapy in women of 40 years of age or younger with atypical hyperplasia or early endometrial cancer (FIGO grade I G1) who wish to preserve their fertility. These women undergo gestagen treatment: medroxyprogesterone acetate, megestrol acetate or levonorgestrel released from an intrauterine device. Exclusion criteria for fertility-sparing treatment are as follows: clear cell carcinoma, papillary serous carcinoma, myometrial invasion or malignant changes in the adnexa and lymph nodes identified by magnetic resonance imaging. Pregnancy and delivery of a child are possible when the above criteria are adhered to, which may then be followed by appropriate oncological procedures. Clinical studies on hysteroscopy for endometrial cancer have noted cancer cell dissemination within the peritoneum. Some studies indicate, however, that the problem is controversial: a decrease in intrauterine pressure below 80, and optimally 50 mm Hg, significantly reduces this risk.

Keywords: hysteroscopy, endometrial cancer, fertility-sparing therapy
Leiomyosarcoma of the broad ligament of the uterus – a literature review and case report
Curr Gynecol Oncol 2016, 14 (4), p. 237–246
DOI: 10.15557/CGO.2016.0029

Introduction: Leiomyosarcoma of the broad ligament of the uterus occurs extremely rarely, usually in postmenopausal women. Objective: A literature review on the occurrence of leiomyosarcoma of the broad ligament and the presentation of a case of leiomyosarcoma of the left broad ligament. Material and methods: Available publications containing case reports regarding leiomyosarcoma of the broad ligament of the uterus were analyzed. Medical records of a 57-year-old patient who underwent surgery at the Department of Gynecology and Obstetrics of the District Hospital in Lipsko n. Wisłą, Poland, were analyzed retrospectively. Earlier surgical treatment and postoperative oncological treatment as well as neurosurgical treatment due to metastasis were also taken into account. Results: In the PubMed database 27 papers reporting 28 cases of leiomyosarcoma of the broad ligament had been published by 28.08.2016. In the case presented in this paper the patient was referred to the department with a diagnosis of left ovarian tumor. A left parametrial and adnexal tumor was removed via laparotomy. The right ovary was excised to the extent that was possible. The appendix and greater omentum were removed. Histopathological diagnosis (tumor of the left parametrium): Leiomyosarcoma G2. The treatment was continued at a cancer clinic, at the Central Teaching Hospital of the Military Medical Academy in Warsaw (at the Department of Neurosurgery) and subsequently at the Department of Radiotherapy of the Holy Cross Cancer Center in Kielce, Poland. The patient died 26 months after the operation. Conclusions: The diagnosis of leiomyosarcoma of the broad ligament in the preoperative period is very difficult. After surgical treatment follow-up diagnostic imaging is necessary due to the aggressive course of the disease.

Keywords: leiomyosarcoma of the broad ligament of the uterus, broad ligament, broad ligament tumor
Lipoleiomyoma of the broad ligament of the uterus – a literature review and clinical situation report
Curr Gynecol Oncol 2016, 14 (4), p. 247–254
DOI: 10.15557/CGO.2016.0030

Lipoleiomyoma is a benign tumor of the female reproductive organs. This histologic subtype of leiomyoma also includes pure lipoma and fibrolipomyoma. Lipoleiomyoma is composed of adipocytes, smooth muscle cells and fibrous tissue. The aim of the paper is to present a case of lipoleiomyoma of the right broad ligament of the uterus because of the extremely rare occurrence of this tumor. A fifty-year-old patient underwent total hysterectomy with bilateral salpingooophorectomy due to a tumor located in the lower abdomen and pelvis. A tumor of the right broad ligament of the uterus and the right adnexa was removed; subsequently, hysterectomy and left adnexectomy were performed. A preoperative diagnosis of lipoleiomyoma of the right broad ligament of the uterus was made following the analysis of the results of diagnostic imaging, i.e. ultrasound and computed tomography scans as well as of the clinical picture of inferior vena cava syndrome. The final diagnosis was made based on microscopic examination of the postoperative material. The analysis of available literature indicates that to date 10 cases of lipoleiomyoma of the broad ligament of the uterus have been presented in English-language medical literature.

Keywords: lipoleiomyoma, broad ligament of the uterus, parametrial myomas