2018, Vol 16, No 3
Unexpected malignancy diagnosed in presumed symptomatic and asymptomatic endometrial polyps and submucosal myomas after hysteroscopic resection
Curr Gynecol Oncol 2018, 16 (3), p. 143–149
DOI: 10.15557/CGO.2018.0017

Hysteroscopy is the treatment of choice of benign intrauterine conditions, whenever feasible. During hysteroscopic procedures performed with the intent of resecting myomas and polyps, there is a potential risk of an unexpected diagnosis of an occult malignant lesion. Objective: To estimate the incidence of occult uterine malignancy in women undergoing hysteroscopic electroresection due to a diagnosis of benign uterine lesions: endometrial polyps and submucosal myomas, by ultrasound. Material and methods: The electronic database of patients hospitalized between January 2010 and December 2016 in the Department of Gynecology and Oncology of the Jagiellonian University was searched for women who had undergone hysteroscopic surgery due to presumed endometrial polyps and submucosal myomas. Medical records of 1,006 eligible women were analyzed. Results: Ten cases (10/1,006; 1%) of occult endometrial cancer, 2 cases (2/1,006; 0,2%) of low-grade endometrial stromal sarcoma and 3 cases (3/1,006; 0,3%) of atypical endometrial hyperplasia were found postoperatively. One case of ovarian cancer coexisting with endometrial cancer was diagnosed. Of the factors analyzed, only age, menopausal status and abnormal uterine bleeding turned out to be significant endometrial cancer risk factors. Too few sarcoma cases did not allow similar estimates. We did not observe worsening of the prognosis, and all 15 patients who underwent hysteroscopic resection of the unforeseen malignancy or precancerous lesion are still alive within 2–8 years of follow-up. Conclusions: The incidence of unlooked-for malignancy in patients with benign intracavitary lesions, i.e. endometrial polyps and submucosal myomas, is relatively high. No negative effects of hysteroscopic resection on potential further treatment and prognosis have been proven so far. High risk of malignancy in women with presumed benign intracavitary lesions may indicate that not all these women are appropriate candidates for laparoscopic procedures with power morcellation, particularly when no previous histopathological verification is ordered.

Keywords: hysteroscopy, occult malignancy, endometrial cancer
Factors influencing surgical treatment of breast cancer in elderly patients
Curr Gynecol Oncol 2018, 16 (3), p. 150–158
DOI: 10.15557/CGO.2018.0018

Background: Age-related factors, such as comorbidities, psychophysical status and social conditions, make it necessary to individualize anticancer treatment in some patients. The purpose of the study was to assess factors affecting the extent of surgical treatment in elderly breast cancer patients. Material and methods: The study included 104 women aged 65–93 years, who were treated for breast cancer in a single medical center between 2015 and 2016. A standard evaluation form was completed for each patient, excluding personal data and age, but containing clinical data necessary for the qualification for surgery. Based on the completed questionnaires, hypothetical qualification for surgery was performed by a primary medical team. The results of the anonymous qualification were subsequently compared with the previous, actual qualification, and – based on medical documentation – an attempt was made to identify factors affecting the individualization of surgical treatment. Results: Modification of the actual treatment compared to the anonymous qualification was reported for 34% of patients in the study group. More extensive surgeries were performed in 28, less extensive in 7; more radical breast surgery in 22, and more radical surgery in the area of axillary lymph nodes in 10 patients. Five patients underwent minor breast surgery and one patient – a less extensive surgery of the lymphatic system. Conclusions: Surgical decisions depended on patient’s overall health, comorbidities, anatomical aspects and personal preferences regarding the type of therapy. It was shown that age, tumor size and previous neoadjuvant treatment caused no discrepancies between the anonymous and the actual qualification.

Keywords: breast cancer, old age, surgical treatment
Retroperitoneal soft tissue sarcomas
Curr Gynecol Oncol 2018, 16 (3), p. 159–166
DOI: 10.15557/CGO.2018.0019

Retroperitoneal soft tissue sarcomas are rare and account for approximately 10–15% of all soft tissue sarcomas. The incidence is more or less equal in males and females, with tumors usually developing in the fifth and sixth decades of life. Clinical signs and symptoms of retroperitoneal sarcomas are non-specific. The disease presents at a late stage, and the symptoms are directly associated with the tumor compressing adjacent abdominal structures. Contrast-enhanced abdominal and pelvic computed tomography is the preferred imaging test. It enables assessment of the size of the primary tumor and its relationship with adjacent structures, vessels and nerves. Currently, core needle biopsy is preferred when extensive, multiple organ resections are planned (e.g. a tumor with a kidney). For better anatomic orientation, description and clinical usefulness, it is proposed to divided the retroperitoneal space into three zones: unpaired zone I (medial), paired zone II (lateral) and unpaired zone III (pelvic). The two most common histological types of retroperitoneal sarcomas (of over a hundred known subtypes) are liposarcoma and leiomyosarcoma, which together account for approximately 75% of all cases. Radical resection remains the primary treatment method in patients with advanced regional disease without distant metastases. Only radical resection offers long-term survival and even complete recovery. En bloc resection (resection of a tumor together with affected organs) of adjacent structures may allow one to obtain a broad and infiltration-free margin. Non-specific signs and symptoms as well as late diagnosis result in worse prognosis in these patients. Due to the relative rare occurrence of these tumors and complexity of their treatment, patients should be treated only in cancer centers offering a multidisciplinary approach. Moreover, such centers have appropriate experience, enabling rapid, effective and individualized treatment planning.

Keywords: retroperitoneal soft tissue sarcomas, anatomy of the retroperitoneum, diagnosis and treatment
The role of selected populations of immune cells in the pathogenesis of endometriosis
Curr Gynecol Oncol 2018, 16 (3), p. 167–176
DOI: 10.15557/CGO.2018.0020

Endometriosis is diagnosed in approximately 5–10% of women in their childbearing years and is characterized by the presence of endometrial tissue outside the uterus. The translocated endometrial cells are able to infiltrate adjacent tissues and distant organs, leading to their dysfunction. Despite numerous studies on the pathogenesis of endometriosis, its etiology has not yet been clearly explained. Predisposing factors include hyperestrogenism, congenital uterine anomalies, early menarche, and short menstrual cycles with long and heavy bleeding. Disturbances in the number and function of immune cells as well as the presence of factors determining the survival, implantation and proliferation of endometrial cells have been shown in patients with endometriosis. The activity of both peripheral and peritoneal macrophages, NK cells, cytotoxic lymphocytes and dendritic cells is affected. These cells are responsible for eliminating erythrocytes, menstrual blood cells and cells undergoing apoptosis. Furthermore, the latest research indicates the presence and altered activity of regulatory T cells and myeloid-derived suppressor cells in patients with endometriosis. However, it is still not known whether dysfunctions of these cell populations induce endometriosis or whether they are a consequence of ectopic endometrial proliferation. According to latest reports, endometrial foci may be precursors of endometrioid or clear-cell ovarian carcinoma. A thorough understanding of the mechanisms underlying the disorders associated with the above-mentioned cell populations may be crucial for identifying patients at increased risk of endometriosis-associated ovarian tumor and implementing appropriate preventive measures. The paper describes the role of selected immune cell populations in stimulating implantation, proliferation and angiogenesis in patients with endometriosis.

Keywords: endometriosis, macrophages, DCs, Treg, MDSCs
Surgical limits in gynecologic oncology
Curr Gynecol Oncol 2018, 16 (3), p. 177–182
DOI: 10.15557/CGO.2018.0021

Surgical treatment plays a key role in the therapeutic management of patients diagnosed with malignancy. In 2017, standards for the diagnosis and surgical treatment of gynecologic cancers were developed and published by the Polish Gynecological Oncology Society. Preoperative consultation with other specialists is needed in patients with comorbidities. A multidisciplinary surgical approach is necessary in many cases. In 2017, Denis Querleu presented criteria limiting the implementation of optimal surgery in the “International Journal of Gynecological Cancer.” In the case of disseminated cancer, where there is no possibility to perform radical procedure, ultra-radical (extensive) surgeries should be avoided as they are associated with high complication rates. Neoadjuvant systemic therapy seems more beneficial. The paper attempts to answer the question on when to take the risk of surgery. Based on all necessary additional investigations, a surgeon is able to assess whether there are conditions for optimal cytoreduction. Once consent is obtained from a patient motivated to undergo aggressive treatment, proper preoperative management is necessary – parenteral nutrition to obtain adequate levels of serum proteins, preparation of the gastrointestinal tract, frequent ureteral splinting for better ureteral identification as well as patient consent for colostomy and blood product transfusion. The paper includes general guidelines for the qualification for surgical treatment of gynecologic cancer.

Keywords: gynecologic cancer, surgical treatment, surgical limits
B3 category in breast core needle biopsy – observation or surgical treatment?
Curr Gynecol Oncol 2018, 16 (3), p. 183–189
DOI: 10.15557/CGO.2018.0022

Ultrasound imaging of the breast is an essential part of comprehensive gynecologic patient care. In many countries, gynecologists and gynecologic oncologists not only perform ultrasound scans, but also carry out histopathological verification of breast focal lesions with the use of various biopsy techniques. Histopathological diagnoses of the B3 category, i.e. lesions of uncertain malignant potential, are the most controversial. They primarily include intraductal papilloma, atypical ductal hyperplasia, atypical lobular hyperplasia, classic lobular carcinoma in situ, flat epithelial atypia, phyllodes tumor, radial scar and complex sclerosing lesion. Despite their benign histological nature, these pathologies may accompany malignant hyperplasia, and a diagnosis established on the basis of the biopsy material carries a certain risk of underestimation. In this paper, we reviewed literature concerning further treatment of patients following a core needle biopsy or a vacuum-assisted biopsy diagnosis of B3 lesions. According to the literature data, such treatment is not uniform and depends not only on the lesion type, but also on the method used to verify it. Each time, it is also recommended to carry out a thorough clinical and pathological correlation and an assessment of how representative the specimens are. It has been shown that not all patients must be selected for surgery, and an increasing number of publications indicate the possibility of maintaining only an imaging follow-up program.

Keywords: B3 lesions, breast surgery, uncertain malignant potential, core needle biopsy, vacuum-assisted biopsy
Mitochondrial dysfunction in ovarian cancer
Curr Gynecol Oncol 2018, 16 (3), p. 190–196
DOI: 10.15557/CGO.2018.0023

Mitochondria are present in almost all eukaryotic cells, except for red blood cells, and are primarily responsible for the production of ATP, which is a product of aerobic respiration. Mitochondrial DNA (mtDNA) is a circular molecule composed of 16,596 base pairs and responsible for coding 37 of all 25,000 genes. Mutations impair energy efficiency of mitochondria, and ultimately the functioning of cells and tissues. In mtDNA, mutations take place faster than in nuclear DNA. The reason for the increased rate of mutation in mtDNA is higher exposure to reactive oxygen species that arise from oxidative phosphorylation and damage unprotected mtDNA histone proteins. The first discovery suggesting a link of cancerous diseases with mitochondrial damage was the observation of the shift of the respiration process towards glycolysis. Cancer cells actively metabolize glucose to lactic acid, without the use of oxygen despite its presence. Respiratory chain defects may be associated with the formation of free radicals and an increase in oxidative stress in cancer cells. Mutations in mitochondrial DNA are most often T→C or G→A transitions and are limited to four regions of the mitochondrial genome: the D-loop, 12S rRNA, 16S rRNA and cytochrome b. Mitochondrial DNA dysfunctions are observed in women with ovarian cancer and in other disease entities, and the use of chemotherapy seems to damage mtDNA to a small degree. The modification of the currently used chemotherapy in patients with ovarian cancer can contribute to an increase in mtDNA damage, resulting in improved treatment efficacy and longer survival.

Keywords: ovarian cancer, mitochondria, mtDNA, mutation, chemotherapy