Deirdre Pallister

• Associate specialist breast clinician
• Jarvis Breast Screening Centre, Guildford
• and Royal Marsden Hospital, London, UK

This procedure involves intravenous injection of a special dye that is concentrated in areas of endometriosis bipolar depression 311 buy 20 mg geodon with mastercard. Medical therapy may sometimes be required for symptomatic control while waiting for fertility treatment; however mood disorder program buy 20 mg geodon with visa, this is generally not recommended depression fighting foods cheap geodon 20mg mastercard. Evidence suggests that surgery for endometriomas does not necessarily increase fertility outcome while it can further compromise ovarian reserve depression symptoms not sleeping discount geodon online american express, increase the risk of premature ovarian failure anxiety icd 0 buy 80mg geodon, and induce early menopause mood disorder lecture purchase geodon 80mg without a prescription. On the other hand, surgical treatment of endometriomas can be beneficial for certain cases such as in symptomatic patients. Surgical excision of endometriomas greater than 3 cm were previously thought to improve pregnancy rates, but studies show no difference compared to expectant management. Excision of endometriomas is preferable over ablation or drainage, as this technique has been shown to increase clinical pregnancy rates. In patients failing to conceive spontaneously after the initial surgery, assisted reproductive therapy is recommended, as this has been shown to be more effective than repeat surgery. Although controversial, repeat surgery can be considered after failed assisted reproductive treatments, but further studies are needed to determine optimal management of such patients. Medical therapy cannot be first-line treatment for endometriosis because suppression of ovulation interferes with the ability to conceive. It is clear that for symptomatic women with ovarian endometriomas, laparoscopic surgical excision should be undertaken. Otherwise for small lesions (2 cm), follicle aspiration can be accomplished avoiding the endometriomas. In general, the presence of endometriomas tends to decrease the number of oocytes aspirated but may not impair oocyte or embryo quality. There has long been a debate as to whether treating mild endometriotic lesions or implants would improve fertility. Data from the Canadian and Italian studies, taken together, suggest that the pregnancy rates improve with implant ablation (Jacobson, 2002). The way these data should be extrapolated into practice is that if a laparoscopy is being performed in a woman wishing to conceive, visible lesions should be ablated if technically possible rather than ignoring them. Apart from the mechanical factors (endometriomas, adhesions, fibrosis) affecting pregnancy rates, in endometriosis, macrophage and cytokine abnormalities are thought to play a significant role in inhibiting fertility. These factors may affect oocyte quality, fertilization, and embryo quality as well as endometrial receptivity. Therefore, in addition to ablating lesions when present, several strategies have been devised to enhance fecundity. Controlled ovarian stimulation along with intrauterine insemination, an approach to enhance fecundity in women with unexplained infertility, has been found to be beneficial in women with endometriosis. Although an older meta-analysis suggested an approximate 20% reduction in pregnancy rates, (Barnhart, 2002) data suggest that pregnancy rates are comparable unless endometriosis is severe (Hamdan, 2015). This reemphasizes the pathophysiologic consequences involved with having endometriosis (described earlier). The role of surgical therapy in the management of endometriosis is very much dependent on the clinical presentation of the patient and her desire for future fertility. Although there can be a beneficial effect for fertility, a detrimental effect can also be seen. Advanced stages of disease, particularly those involving extrapelvic locations (discussed later), are often best managed in a multidisciplinary fashion. Implants that involve the gastrointestinal tract are the most common site of extrapelvic endometriosis but can be the most challenging to manage. The severity and extent of involvement of the bowel by ectopic endometrium varies from the incidental finding of a spot on the serosa of the bowel to obstruction of the rectosigmoid. In the majority of cases, endometriosis of the gastrointestinal tract involves the sigmoid colon and the anterior wall of the rectum, accounting for approximately 90% of cases (see Video 19. In a series of more than 100 consecutive patients with endometriosis, 13% had histologic evidence of endometriosis in the appendix, whereas only 60% of these cases are detected on gross examination. Of note, 48% of patients with rectosigmoid lesions will also have endometriosis of the ovaries, and 84% will have rectocervical lesions (Hemming, 2009). Classic symptoms of endometriosis of the large bowel include dysmenorrhea (cyclic pelvic cramping and lower abdominal pain) and dyschezia (rectal pain with defecation), especially during the menstrual period. Studies have demonstrated that 25% to 35% of women with advanced endometriosis of the large bowel experience episodic rectal bleeding due to endometriosis extending into the submucosa. A distinct dysfunction of the enteric nervous system has been suggested to be the primary cause of the abnormalities of bowel function in women with endometriosis. It is difficult to differentiate the symptoms associated with endometriosis from the overlapping constellation of symptoms associated with inflammatory disease of the colon or malignancy. Women with a gastrointestinal malignancy usually experience intermittent rather than cyclic intestinal bleeding. Physical exam can also help with diagnosis of deep infiltrating endometriosis invading the rectosigmoid such as by palpation of a pelvic mass or "rectal shelf " on rectovaginal examination. Sigmoidoscopy usually demonstrates absence of a mucosal lesion in addition to fixation and immobility of the anterior rectal wall. Donnez and coworkers speculated that endometriosis of the rectovaginal septum is a disease process more closely related to foci of adenomyosis than endometriosis (Donnez, 1997). Surgery should generally be performed in coordination with a multidisciplinary team. Although no consensus exists, bowel resection generally is indicated in symptomatic women when lesions are greater than 2 cm, greater than 30% of the circumference is involved, and when there is invasion into the inner muscularis layer, which may require bowel resection (see Video 19. When surgery is indicated, while still unclear which is better, bowel resection can be done via either segmental or discoid resection. Parameters that should be considered in surgical planning include size, number and depth of lesions, extent of bowel circumference involvement, distance to anal verge, and presence of lymph node involvement. Endometriosis in the female pelvis occasionally produces dysfunction in adjacent pelvic organs. Approximately 10% of women with endometriosis have involvement of the urinary tract, which most commonly involves endometriotic implants and associated retroperitoneal fibrosis located in the peritoneum overlying the ureter or the bladder. In most cases an incidental finding of aberrant endometrial glands and stroma is discovered on the bladder peritoneum and anterior cul-de-sac. The most serious consequence of urinary tract involvement is ureteral obstruction, which occurs in about 1% of women with moderate or severe pelvic endometriosis. Interestingly, approximately 50% of women with endometriosis of the urinary tract have a history of previous pelvic surgery. The lesions may develop from implanted endometrium during cesarean delivery or may be an extension from adenomyosis of the anterior uterine wall. Patients with endometriosis involving the urinary tract have nonspecific clinical presentations. One of three women with documented complete ureteral obstruction secondary to endometriosis has no pelvic symptoms whatsoever. The clinical challenge is to diagnose minimal ureteral obstruction at an early stage, before loss of renal function. The obstruction is almost always in the distal one third of the course of the ureter. The importance of an imaging study to diagnose ureteral compromise in all women with retroperitoneal endometriosis cannot be overemphasized. Endometriosis of the bladder is discovered most often in the region of the trigone or the anterior wall of the bladder (Video 19. Treatment of endometriosis of the peritoneum over the bladder can be accomplished by medical or surgical means. Ureteral obstruction may be intrinsic, from active endometriosis, or extrinsic, from long-standing fibrotic reactions to retroperitoneal inflammation. Extrinsic endometriosis is three to five times more common than the intrinsic form. However, long-term follow-up with serial ultrasound imaging or intravenous pyelograms must be undertaken to ensure that the disease process does not recur. Surgical therapy is the preferred treatment for ureteral obstruction secondary to endometriosis (Video 19. The most common surgical approaches include removal of the uterus and both ovaries and the relief of urinary obstruction by ureterolysis or by ureteroneocystostomy. If ureterolysis is performed, peristalsis in the involved segment of the ureter should be observed, along with adequate resection of the endometriosis and surrounding inflammation in the retroperitoneal space. Ureteroneocystostomy has the advantage of bypassing the urinary obstruction and making it technically easier to resect the area of endometriosis and associated retroperitoneal fibrosis. Obstetrics & Gynecology Books Full 19 Endometriosis 441 A Endometriotic implants B Liver Rt. However, if a patient is symptomatic, the most common presentation of diaphragmatic endometriosis is right-sided catamenial pneumothorax. Other signs and symptoms can include dyspnea, chest pain, shoulder pain, hemoptysis, and the presence of pulmonary nodules. Medical suppressive therapy is the first approach, although surgery, including pleurodesis, may be considered. Possible causal factors of endometriosis include retrograde menstruation, coelomic metaplasia, vascular metastasis, immunologic changes, iatrogenic dissemination, and a genetic predisposition. Grossly, endometriosis appears in many forms, including red, brown, black, white, yellow, pink, or clear vesicles and lesions. Approximately 10% of teenagers who develop endometriosis have associated congenital outflow obstruction. The primary long-term goal in the management of a woman with endometriosis is attempting to prevent progression or recurrence of the disease process. Classic symptoms of endometriosis of the large bowel include cyclic pelvic cramping and lower abdominal pain and rectal pain with defecation, especially during the menstrual period. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Selective progesterone receptor modulators and progesterone antagonists: mechanisms of action and clinical applications. Role of K-ras and ten in the development of mouse models of endometriosis and endometrioid ovarian cancer. Molecular profiling of experimental endometriosis identified gene expression patterns in common with human disease. Gestrinone versus a gonadotropin-releasing hormone agonist for the treatment off pelvic pain associated with endometriosis: a multicenter, randomized, double-blind study. Influence of endometriosis on assisted reproductive technology outcomes: a systematic review and metaanalysis. Racial and ethnic disparities in benign gynecologic conditions and associated surgeries. Decreased levels of the potent regulator of monocyte/macrophage activation, interleukin-13, in the peritoneal fluid of patients with endometriosis. Zur Frage der heterotopen Epithelwucherung, insbe Suggested Readings can be found on ExpertConsult. Treatment of endometriosis with a long-acting gonadotropin-releasing hormone agonist plus medroxyprogesterone acetate. Increased expression of cyclooxygenase-2 in local lesions of endometriosis patients. Sexual activity, contraception, and reproductive factors in predicting endometriosis. Cortical and trabecular bone mineral content in women with endometriosis: effect of gonadotropin-releasing hormone agonist and danazol. Clinical, endocrine, and metabolic effects of two doses of gestrinone in treatment of pelvic endometriosis. Depot leuprolide acetate versus danazol for treatment of pelvic endometriosis: changes in vertebral bone mass and serum estradiol and calcitonin. A randomized, controlled trial of clomiphene citrate and intrauterine insemination in couples with unexplained infertility or surgically corrected endometriosis. Serial laparoscopies over 30 months show that endometriosis in captive baboons (Papio anubis, Papio cynocephalus) is a progressive disease. Role of K-ras and Pten in the development of mouse models of endometriosis and endometrioid ovarian cancer. Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: a randomized, placebo-controlled, double-blind study. Superovulation with human menopausal gonadotropins in the treatment of infertility associated with minimal or mild endometriosis: a controlled randomized study. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Endometrial patterns during danazol and buserelin therapy for endometriosis: comparative structural and ultrastructural study. Gonadotropin-releasing hormone agonist plus estrogen-progestin "add-back" therapy for endometriosis-related pelvic pain. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case-control study. Gestrinone Italian Study Group: Gestrinone versus a gonadotropin-releasing hormone agonist for the treatment of pelvic pain associated with endometriosis: a multicenter, randomized, double-blind study. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. Peritoneal macrophages from patients with endometriosis release growth factor activity in vitro. Adenocarcinoma arising in extragonadal endometriosis: an immunohistochemical study. Soluble vascular endothelial growth factor receptor 1 inhibits edema and epithelial proliferation induced by 17 beta-estradiol in the mouse uterus. Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation. Administration of nasal nafarelin as compared with oral danazol for endometriosis: a multicenter double-blind comparative clinical trial.

Because most diseases in women occur after menopause depression symptoms fatigue buy geodon 40mg fast delivery, the onset of menopause heralds an important opportunity to institute prevention strategies for prolonging and improving the quality of life for women depression exercise cheap 20 mg geodon. In younger postmenopausal women who are receiving hormonal therapy for symptoms anxiety prayer buy genuine geodon on-line, the benefits outweigh risks with standard doses; lowering doses further decreases risks headspace depression test order geodon 20 mg visa. There is no risk of coronary disease and possibly some benefit with early treatment; there are small risks of venous thrombosis and possibly of ischemic stroke depression hallucinations buy geodon 20mg otc, which can be minimized or eliminated with lower doses or transdermal therapy anxiety attack help discount geodon 80mg with amex. These findings suggest a potential role of estrogen as a prevention therapy after menopause, although the primary indication is for symptom control and osteoporosis prevention. Estrogen alone and possibly the use of natural progestogen do not substantially increase the risk. Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a metaanalysis. Resumption of ovarian function and pregnancies in 358 patients with premature ovarian failure. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. Comparison between degree of systemic absorption of vaginally and orally administered estrogens at different dose levels in postmenopausal women. Suppression of postmenopausal ovarian steroidogenesis with the luteinizing hormone-releasing hormone agonist goserelin. Efficacy of estrogen supplementation in the treatment of urinary incontinence: the Continence Pro-gram for Women Research Group. The influence of oestrogens on the well being and mental performance in climacteric and postmenopausal women. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. On rho, a marrow mediator, and estrogen: their roles in bone strength and "mass" in human females, osteopenias, and osteoporosis-insights from a new paradigm. Increase of proopi-omelanocortin-related peptides during subjective menopausal flushes. Insulin resistance in postmenopausal women with metabolic syndrome and the measurements of adiponectin, leptin, resistin, and ghrelin. Lack of effect of raloxifene on coronary artery atherosclerosis of postmenopausal monkeys. Estradiol-17b attenuates acetylcholine-induced coronary arterial constriction in women but not men with coronary heart disease. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the fracture intervention trial. Regulation of growth hormone and somatomedin-C secretion in postmenopausal women: effect of physiologic estrogen replacement. Plasma adiponectin concentration in healthy pre- and postmenopausal women: relationship with body composition, bone mineral, and metabolic variables. The tissue selective estrogen complex: a novel approach to the treatment of menopausal symptoms. Hip fracture in postmenopausal women after cessation of hormone therapy: results from a prospective study in a large health management organization. Effects of sex and age on bone microstructure at the ultradistal radius: a population-based noninvasive in vivo assessment. Evaluation of the clinical relevance of benefits associated with transdermal testosterone treatment in postmenopausal women with hypoactive sexual desire disorder. The effects of hormone replacement therapy on hypothalamic neuropeptide gene expression in a primate model of menopause. Mutation in the follicle-stimulating hormone receptor gene causes hereditary hypergonadotropic ovarian failure. Initiation of hormone replacement therapy after acute myocardial infarction is associated with more cardiac events during follow up. Characteristicas del: patron de sangrado menstrual; en un grupo de mujeres normales de Durango. Identification of 3 beta-hydroxysteroid dehydrogenase as novel target of steroid-producing cell autoantibodies: association of autoantibodies with endocrine autoimmune disease. Topical estrogen accelerates cutaneous wound healing in aged humans associated with an altered inflammatory response. Female androgen insufficiency: the Princeton consensus statement on definition, classification, and assessment. Reversal of apparent premature ovarian failure in a patient with myasthenia gravis. Million Women Study Collaborators: Breast cancer and hormone-replacement therapy in the Million Women Study. Effect of estradiol implant on noradrenergic function and mood in menopausal subjects. Cultural significance and physiological manifestations of menopause, a bicultural analysis. Increased bone mass as a result of estrogen therapy in a man with aromatase deficiency. Preliminary evidence for impaired estrogen receptor-a protein expression in osteoblasts and osteocytes from men with idiopathic osteoporosis. A study of the relationship of skin collagen content, skin thickness and bone mass in the postmenopausal woman. A prospective longitudinal study of serum testosterone, dehydroepiandrosterone sulfate, and sex hormone-binding globulin levels through the menopause transition. The management of persistent menopausal symptoms with oestradiol-testosterone implants: clinical, lipid and hormonal results. Noninvasive assessment of coronary microcirculatory function in postmenopausal women and effects of short-term and long-term estrogen administration. Hormone replacement therapy and risk of venous thromboembolism in post-menopausal women: systematic review and meta-analysis. Short-term effects of smoking on the pharmacokinetic profiles of micronized estradiol in postmenopausal women. Alveolar and postcranial bone density in postmenopausal women receiving hormone/estrogen replacement therapy. Inhibition of postmenopausal atherosclerosis progression: a comparison of the effects of conjugated equine estrogens and soy phytoestrogens. A comparison of tibolone and conjugated equine estrogens effects on coronary artery atherosclerosis and bone density of postmenopausal monkeys. Steroidogenic enzyme p450c17 is expressed in the embryonic central nervous system. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fracture and coronary heart disease among white postmenopausal women. The potential impact of new National Osteoporosis Foundation guidance on treatment patterns. Body composition, visceral fat distribution and fat oxidation in postmenopausal women using oral or transdermal oestrogen. Estrogen effects on the urethra: beneficial effects in women with genuine stress incontinence. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Obstetrics & Gynecology Books Full Bibliography Falconer C, Ekman Orderberg G, Ulmasten U, et al. Changes in para-urethral connective tissue at menopause are counteracted by estrogen. Efficacy of estrogen supplementation in the treatment of urinary incontinence: the Continence Program for Women Research Group. The role of changes in mechanical usage set points in the pathogenesis of osteoporosis. Pulsatility index in internal carotid artery in relation to transdermal oestradiol and time since menopause. Increase of proopi-omelanocortinrelated peptides during subjective menopausal flushes. Growth hormone-releasing activity of hexarelin, a new synthetic hexapeptide, after intravenous, subcutaneous, intranasal, and oral administration in man. Effects of physiological levels of estrogen on coronary vasomotor function in postmenopausal women. Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. Age-related changes of the population of human ovarian follicles: increase in the disappearance rate of non growing and early growing follicles in aging women. Postmenopausal hormone therapy and stroke: role of time since menopause and age at initiation of hormone therapy. Executive summary of the stages of reproductive aging workshop + 10: addressing the unfinished agenda of staging reproductive aging. Anti-mullerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation. Effects of estrogen replacement on the progression of coronary-artery atherosclerosis. The use of intravaginal estrogen cream in genuine stress incontinence: a double blind clinical trial. Oral and intravaginal oestrogens alone and in combination with alpha adrenergic stimulation in genuine stress incontinence. Effects of sex and age on the 24-hour profile of growth hormone in man: importance of endogenous estradiol concentrations. Presented at the14th World Congress on Menopause of the International Menopause Society. The roles of osteoprotegerin and osteoprotegerin ligand in the paracrine regulation of bone resorption. Progestogen addition during oestrogen replacement therapy: effects on vasomotor symptoms and mood. Inhibin and estradiol responses to ovarian hyperstimulation: effects of age and predictive value for in vitro fertilization outcome. Familial premature ovarian failure due to an interstitial deletion of the long arm of the X chromosome. Intravaginal dehydroepiandrosterone (prasterone), a highly efficient treatment of dyspareunia. Does the route of administration for estrogen hormone therapy impact the risk of venous thromboembolism The relationship of circulating dehydroepiandrosterone, testosterone, and estradiol to stages of the menopausal transition and ethnicity. Behavioral stress responses in premenopausal and postmenopausal women and the effects of estrogen. A possible bimodal effect of estrogen on insulin sensitivity in postmenopausal women and the attenuating effect of added progestin. Effect of lower doses of conjugated equine estrogen with and without medroxyprogesterone acetate on bone in early postmenopausal women. Randomized controlled study of effect of parathyroid hormone on vertebral-bone mass and fracture incidence among postmenopausal women on oestrogen with osteoporosis. Evaluation of cardiovascular event rates with hormone therapy in healthy postmenopausal women: results from four large clinical trials. Metabolic parameters and steroid levels in postmenopausal women receiving lower doses of natural estrogen replacement. Comparative effects of oral esterified estrogens with and without methyltestosterone on endocrine profiles and dimensions of sexual function in postmenopausal women with hypoactive sexual desire. Is low-dose hormone replacement for postmenopausal women efficacious and desirable. Pubertal progression in the presence of elevated serum gonadotropins in girls with multiple endocrine deficiencies. Congenital adrenal hyperplasia secondary to 17-hydroxy-lase deficiency: two sisters with amenorrhea, hypokalemia, hypertension and cystic ovaries. Biological effects of various doses of vaginally administered conjugated equine estrogens in postmenopausal women. Nongenomic, estrogen receptor-mediated activation of endothelial nitric oxide synthase. Effect of oestrogen and testosterone implants on psychological disorders in the climacteric. Hormone replacement therapy and cardiovascular disease: a statement for healthcare professionals from American Heart Association. Estrogen replacement therapy for treatment of mild to moderate Alzheimer disease: a randomized controlled trial. The use of hormone therapy for the maintenance of urogynecological and sexual health. Oestrogen and progesterone hormone replacement therapy for peri-menopausal and post-menopausal women: weight and body fat distribution. Modulation of transforming growth factor- production in normal human osteoblast-like cells by 17-estradiol and parathyroid hormone. Effects of salcatonin given intranasally on bone mass and fracture rates in established osteoporosis: a dose-response study. Exercise and other factors in the prevention of hip fracture: the leisure world study. Treatment of postmenopausal osteoporosis with slow-release sodium fluoride: final report of a randomized controlled trial.

Prognostic factors for outcome of and survival after second-look laparotomy in patients with advanced ovarian carcinoma depression test embarrassing bodies buy cheap geodon on-line. Intraperitoneal cisplatin chemotherapy versus abdominopelvic irradiation in ovarian carcinoma patients after second-look laparotomy depression symptoms nausea discount geodon 20mg amex. Results of interval debulking surgery compared with primary debulking surgery in advanced stage ovarian cancer anxiety reduction 20mg geodon visa. Obstetrics & Gynecology Books Full Bibliography Musella A depression symptoms unemployment purchase 40 mg geodon amex, Marchetti C depression test form discount 80mg geodon free shipping, Palaia I depression test webmd generic 20mg geodon with visa, et al. Secondary cytoreduction in platinumresistant recurrent ovarian cancer: a single-institution experience. Laparoscopic management of early ovarian and fallopian tube cancers: surgical and survival outcome. Immature (malignant) teratoma of the ovary: a clinical and pathologic study of 58 cases. Diaphragmatic peritonectomy versus full thickness diaphragmatic resection and pleurectomy during cytoreduction in patients with ovarian cancer. A review of the close surveillance policy for stage I female germ cell tumors of the ovary and other sites. Rectosigmoid resection at the time of primary cytoreduction for advanced ovarian cancer. Five-year survival for stage Ic or stage I grade 3 epithelial ovarian cancer treated with cisplatin-based chemotherapy. Percutaneous endoscopic gastrostomy tube placement in patients with malignant bowel obstruction due to ovarian carcinoma. Palliative surgery for bowel obstruction in recurrent ovarian cancer: an updated series. Ovarian tumors of borderline malignancy (tumors of low malignant potential): a critical appraisal. Intraperitoneal recombinant interferon gamma in ovarian cancer patients with residual disease at secondlook laparotomy. Pegylated liposomal Doxorubicin and carboplatin compared with paclitaxel and carboplatin for patients with platinum-sensitive ovarian cancer in late relapse. Small cell carcinoma of the ovary with hypercalcemia: report of a case of survival without recurrence 5 years after surgery and chemotherapy. A clinicopathologic multivariate analysis affecting recurrence of borderline ovarian tumors. Risk factors for anstomotic leak after recto-sigmoid resection for ovarian cancer. Pseudomyxoma peritonei in women: A clinicopathologic analysis of 30 cases with emphasis on site of origin, prognosis, and relationship to ovarian mucinous tumors of low malignant potential. Clinical relevance of retroperitoneal involvement from epithelial ovarian tumors of borderline malignancy. Ten-year follow-up of ovarian cancer patients after second-look laparotomy with negative findings. Combined transvaginal B-mode and color Doppler sonography for differential diagnosis of ovarian tumors: results of a multivariate logistic regression analysis. Relationship between lifetime ovulatory cycles and overexpression of mutant p53 in epithelial ovarian cancer. Neoadjuvant chemotherapy for low-grade serous carcinoma of the ovary or peritoneum. Gonadoblastoma: a gonadal tumor related to dysgerminoma (seminoma) and capable of sex hormone production. Conclusions and recommendations from the Helene Harris Memorial Trust Fund Biennial International Forum on ovarian cancer, May 4-7, 1995. Ovarian cysts in premenopausal and postmenopausal tamoxifen-treated women with breast cancer. Different types of rupture of the tumor capsule and the impact on survival in early ovarian carcinoma. Risk factors for progression to invasive carcinoma in patients with borderline ovarian tumors. Relative frequency of malignant paraovarian tumors: Should paraovarian tumors be aspirated The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Reproductive function after conservative surgery and chemotherapy for malignant germ cell tumors of the ovary. Conservation of in vitro drug resistance patterns in epithelial ovarian carcinoma. Recurrent ovarian granulosa cell tumor: a case report of a dramatic response to taxol. Impact of adjuvant chemotherapy and surgical staging in early-stage ovarian carcinoma: European Organization for Research and Treatment of Cancer-Adjuvant ChemoTherapy in Ovarian Neoplasm trial. A review of four prospective randomized trials including 253 patients with borderline tumors. Cytoreductive surgery in ovarian carcinoma patients with a documented previously complete surgical response. Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Epithelial ovarian cancer: Impact of surgery and chemotherapy on survival during 1977-1990. Neoadjuvant chemotherapy or primary debulking surgery in advanced ovarian carcinoma: a retrospective analysis of 285 patients. A Southwest Oncology Group study for the use of a human tumor cloning assay for predicting response in patients with ovarian cancer. Long-term survival after vinblastine, bleomycin, and cisplatin treatment in patients with germ cell tumors of the ovary: an update. Second-look laparotomy in ovarian germ cell tumors: the Gynecologic Oncology Group experience. Adjuvant therapy of ovarian germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of the Gynecologic Oncology Group. Treatment of malignant ovarian germ cell tumors with preservation of fertility: A report of 28 cases. Mucinous tumors of the appendix associated with mucinous tumors of the ovary and pseudomyxoma peritonei. Cis-platinum/vinblastine/bleomycin combination chemotherapy in advanced or recurrent granulosa cell tumors of the ovary. Survival and reproductive function after treatment of malignant germ cell ovarian tumors. Gershenson Fallopian tube and peritoneal cancers have similar clinical characteristics, patterns of spread, response to treatment, and survival rates when compared with ovarian cancer. In addition, the most common histologic type for all three malignancies is high-grade serous adenocarcinoma. However, fallopian tube and peritoneal cancers have several distinct clinical and pathologic findings. This chapter reviews current information on fallopian tube and peritoneal cancer, with particular emphasis on diagnosis, natural history, and clinical management. It diffusely involves the peritoneal surfaces while sparing or minimally involving the ovaries and fallopian tubes. The incidence of peritoneal carcinoma in the United States has been estimated to be 0. Peritoneal cancer is histologically indistinguishable from epithelial ovarian cancer and has similar clinical characteristics, patterns of spread, response to treatment, and survival rates (Fromm, 1990; Halperin, 2001). However, peritoneal cancer has also been associated with older age at diagnosis and increased rates of obesity when compared with ovarian cancer (Barda, 2004; Jordan, 2008). The germinal epithelium of the ovary and mesothelium of the peritoneum arise from the same embryonic origin, and it was previously suggested that primary peritoneal cancer may develop from a malignant transformation of these cells (Lauchlan, 1972). Another proposed theory was a field effect, with the coelomic epithelium lining the abdominal cavity (peritoneum) and ovaries (germinal epithelium) manifesting a common response to an oncogenic stimulus (Parmley, 1974; Truong, 1990). Molecular studies have been inconclusive in determining whether the tumor arises from the ovarian surface epithelium and spreads throughout the peritoneum or if a multifocal malignant transformation process occurs. Peritoneal carcinoma has therefore become a diagnosis of exclusion when a primary ovarian or fallopian tube carcinoma cannot be identified. However, it has been suggested that many cases of ovarian carcinoma may actually arise from the epithelial lining of the fallopian tube fimbria, thereby grossly underestimating the incidence of primary fallopian tube carcinoma (Kindelberger, 2007; Carlson, 2008a). Similar to ovarian cancer, associated risk factors for fallopian tube and peritoneal cancer include infertility, low parity, early menarche, and late menopause (Gates, 2010). Protective factors include oral contraceptive use, multiparity, breastfeeding, and tubal ligation (Cibula, 2011; Tsilidis, 2011). Similar to those with ovarian cancer, women with peritoneal cancer typically present with pain, abdominal distention, pressure, or gastrointestinal symptoms. Occasionally, primary peritoneal cancer is detected during exploratory surgery for other reasons. In peritoneal and fallopian tube cancers, ascites or peritoneal implants may be present. These studies can provide information regarding the extent of disease and sites of metastatic spread, allowing the physician to plan appropriate intervention and treatment. The updated system uses the same staging for all three entities due to the similar patterns of spread, surgical approach, treatment, and prognosis. However, the staging does require that the site of origin be noted if known (ovary, fallopian tube, peritoneum). Fallopian tube cancer is more common among white women (age-adjusted incidence rate, 0. The presenting symptoms of fallopian tube carcinoma are largely related to the degree of obstruction of the distal tube. Many women are asymptomatic; however, the most commonly reported signs and symptoms include abnormal vaginal bleeding or serosanguineous vaginal discharge (35% to 60%), a palpable adnexal mass (10% to 60%), and crampy lower abdominal pain caused by tubal distention and forced peristalsis (20% to 50%). Hydrops tubae profluens is the term used to describe intermittent expulsion of clear or serosanguineous fluid from the vagina caused by contraction of a distended, distally occluded fallopian tube (Sinha, 1959). The fimbriated end of the fallopian tube is grossly occluded in approximately 50% of patients, resulting in a dilated lumen filled with tumor Obstetrics & Gynecology Books Full 34 Fallopian Tube and Peritoneal Carcinoma Table 34. Most of these are serous carcinomas, followed by endometrioid and clear cell adenocarcinomas. Other rare histologic subtypes include sarcomas, carcinosarcomas, germ cell tumors, and gestational trophoblastic tumors. The most common histologic type is highgrade serous carcinoma, but cases of endometrioid, clear cell, mucinous, and carcinosarcoma have also been reported. Both ovaries must be physiologically normal in size or enlarged by a benign process. Involvement in the extraovarian sites must be greater than involvement on the surface of either ovary. The histologic and cytologic characteristics of the tumor must be predominantly of the serous type that is similar or identical to ovarian serous papillary adenocarcinoma of any grade. Previous reports have shown stage at diagnosis to be evenly distributed among localized disease, regional spread, and distant metastases. However, serous adenocarcinomas are more likely to be diagnosed at advanced stages and endometrioid adenocarcinomas at earlier stages (Stewart, 2007). It can be challenging to distinguish primary fallopian tube carcinoma from ovarian or peritoneal carcinomas. Hu and colleagues (Hu, 1950) initially developed pathologic diagnostic criteria in 1950 for the diagnosis of primary fallopian tube carcinoma. These were subsequently modified by Sedlis and associates in 1978 (Sedlis, 1978), and included the following: 1. A transition can be demonstrated between the malignant and nonmalignant tubal epithelium. The patterns of spread of fallopian tube carcinoma are largely related to the degree of obstruction of the distal tube. If the fimbriated end of the tube is obstructed by tumor, previous injury, or infection, the by-products of tumor growth, such as blood and increased serous fluid, distend the tube and are discharged intermittently through the vagina. If the distal portion of the fallopian tube is patent, the malignancy spreads more easily out the distal end of the tube, resulting in tumor seeding of the peritoneal cavity, ascites, and omental caking. Intraperitoneal spread may also occur as the tumor grows through the muscular wall of the tube. Occult lymph node metastases may be present in patients with tumor that grossly appeared to be confined to the fallopian tube. A staging operation should be performed in patients with apparent early stage disease. This includes omentectomy, pelvic and paraaortic lymph node dissection, and peritoneal biopsies. In cases of advanced disease, cytoreductive surgery with removal of as much visible tumor as possible should be performed. Similar to ovarian cancer, improved survival rates are associated with optimal cytoreduction for fallopian tube and peritoneal cancers. Optimal cytoreduction may be more difficult to achieve in women with widespread peritoneal disease without a predominant pelvic or ovarian mass. Patients with advanced-stage disease are typically treated with a combination of carboplatin and paclitaxel. Many clinical trials for ovarian cancer include fallopian tube and peritoneal cancers Obstetrics & Gynecology Books Full 34 Fallopian Tube and Peritoneal Carcinoma because of their similar clinical and pathologic findings, as well as response to chemotherapeutic agents. Similar to ovarian cancer, neoadjuvant chemotherapy may be considered for patients with fallopian tube cancer and peritoneal cancer who have unresectable disease, a large tumor burden, or medical comorbidities precluding surgery.

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