فهرست مطالب behnaz ghavami

The standard surgery for endometrial cancer can be deferred in some situations, including morbid obesity, comorbidities, and the patient's desire for fertility. One of the options to improve patients' circumstances is bariatric surgery.

Case report: 

This study presented two patients with stage IA, grade I endometrioid endometrial adenocarcinoma. Both patients had morbid obesity and had comorbidities. In case 1, because of fertility preservation, and in case 2, because of severe comorbidities, hormone therapy was started, followed by bariatric surgery after counseling patients. Both patients had acceptable changes in body mass index during follow-up, so cancer surgery through laparoscopy was done. Both patients did not need adjuvant therapy; months after cancer surgery, there is no recurrence, and their body mass index is also decreasing.

Bariatric surgery can improve outcomes in patients with morbid obesity who suffer endometrial cancer.

Various risk assessment tools have been developed to evaluate the risk of hereditary breast/ovarian cancer. This study aims to estimate the risk of breast/ovarian cancer in a sample of the general population in Iran using the IBIS software. A total of 2020 women aged 18-79 years were consecutively selected from the gynecology clinic of Imam Hossein Medical Center between April 2019 and 2021. The Tyrer-Cusick (IBIS) questionnaire was used to collect data on variables such as age, BMI, age at menarche, age at first pregnancy, menopausal status, history of hormone replacement therapy (HRT), and family history of breast/ovarian cancer. The risks of developing breast/ovarian cancer were calculated, with patients having a calculated risk of more than 20% considered high-risk and those below 20% considered low-risk. Out of the 2020 cases studied, 69 (3.4%) were classified as high-risk for developing breast/ovarian cancer. The moderate risk of breast/ovarian cancer in patients with a positive family history was 18.47%, compared to 10.15% in those without a family history. All high-risk individuals had a positive family history, while only 9.4% of the low-risk population had a family history; this difference was statistically significant (p<0.001). Routine assessment of family history of cancer in all patients is recommended, with positive cases being further evaluated using a cancer risk assessment tool and referred for genetic counseling as appropriate.

Malignant transformation in dermoid cysts is rare, and Squamous Cell Carcinoma (SCC) is the most common form. This event often occurs in large tumors and middle-aged women.

Case report: 

In this study, two cases are presented. They were menopause, and abdominal pain and adnexal mass was a common manifestation in both. Case 1 with adenocarcinoma arising in mature cystic teratoma had abnormal tumor markers and was diagnosed with a frozen section during surgery, but case 2 with SCC transformation had normal tumor markers, and the frozen section was not helpful in the first surgery. Both underwent complete staging surgery, and due to stage IC1 in case 1, she received chemotherapy, and in case 2, no adjuvant treatment was needed because of stage IA.

Considering the rarity of malignant transformation in the dermoid cyst, the best surgical approach and adjuvant therapy indications need further research.

 Although laparoscopic myomectomy is an effective procedure for the treatment of uterine myoma, there is no clear consensus regarding its rate of recurrence and associated risk factors.

 This study aimed to investigate the recurrence rate of myoma and its risk factors after laparoscopic myomectomy.

 In a historical cohort study, 172 patients who underwent laparoscopic myomectomy and had a minimum follow-up of 2 years were included. Myoma recurrence was checked semiannually by ultrasound imaging. The demographic, clinical, surgical, sonographic, and laboratory indices of the patients were compared between the recurrent and nonrecurrent groups, both in logistic regression models.

 The mean age of the patients was 35 ± 5.7 years (range: 18 - 47 years). Their mean follow-up time was 26.3 ± 4.2 months (range: 24 - 28). The lesion recurred in 25 (14.5%) out of 172 patients. In the univariate analysis, higher age (OR:1.111, P = 0.015), higher body mass index (OR: 1.124, P = 0.024), gonadotropin-releasing hormone (GnRH) therapy (OR = 3.83, P = 0.027), and more than 1 myoma (OR: 2.60, P = 0.032) were associated with myoma recurrence. In the multiple analysis, a higher body mass index (OR: 1.222, P = 0.003) was a significant risk factor for myoma recurrence.

 Laparoscopic myomectomy is an effective procedure for the treatment of uterine myoma and can be used as a uterus-preserving surgical alternative in patients of reproductive age. A more radical surgical procedure might be used for patients with multiple risk factors, as revealed in the present study.

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor that originates from deep layers of the dermis and mainly is common in young adults to middle age. This tumor is rare in the vulva.

A 53-year-old multiparous menopause female had complained of asymptomatic swelling of the right labia major. Dermatofibrosarcoma protuberans was reported in primary tumor resection.  Six months later, rapid growing mass recurred in the vulva. The patient underwent radical Vulvectomy and resection of the margin of about 2-3 cm along with bilateral Inguinofemoral lymphadenectomy. The margins of the mass were negative in the frozen section. Microscopic examination revealed that hypercellular neoplasm in dermis comprising monomorphic spindle cells with high mitotic activity, some hyperchromatic nuclei arranged in palisading fashion. Microscopic and IHC study confirmed the conversion of dermatofibrosarcoma protuberans to fibrosarcoma.

This case was presented due to the rarity of dermatofibrosarcoma protuberance in the vulva and pathologic conversion to fibrosarcoma.

Gynecological cancer survivors have been growing, as a result of advancements in national cancer screening strategies, resulting in early-stage diagnosis, and cancer treatments developments. Lack of a valid documented assessment tool to measure their requirements for supportive care is detected. The aim was to develop a comprehensive scale that comprises all features of gynecologic cancer survivors` requirements in Iranian population.

The Cancer Survivors Assessment Questionnaire NCCN2.2020 (National comprehensive cancer network) was translated including the instructions, and the answer choices by two native translators, including one fluent translator and one linguist. For qualitative face validity of the questionnaire at the disposal of 10 specialists were delegated to make the necessary changes. Content validity and content validity index were evaluated in terms of qualitative face validity and quantitative face validity. Necessary changes were applied.

The original Cancer Survivors Assessment Questionnaire NCCN2.2020 (National comprehensive cancer network) was condensed from 27 to 24 questions during the customization process. Questions related to lymphedema, and immunization were eliminated from the survey, as a result of low content validity index and scores. According to the panel of experts, ten questions including number 3, 5, 6, 9, 10, 13, 17, 18, 19, and 25 of the questionnaires were changed to a more suitable and comprehensible ones in Persian language.

We suggest that the Persian version of cancer survivors’ assessment questionnaire be applied in populations with Persian language and that its sensitivity to variation be measured.

Low-grade appendiceal mucinous neoplasm (LAMN) is a very rare condition, diagnosed in 0.2-0.7% of appendectomies. The pathophysiology of the neoplasm involves accumulation of large volume of mucin in the appendiceal lumen, resulting in its obstructive dilation. Most epithelial tumors affecting the appendix are of the mucinous type and are manifested by mucin accumulation within an inflamed appendix with fibrotic and hyalinized wall.

A 29-year-old female presented with a history of chronic and intermittent episodes of abdominal pain and a palpable mass in the right lower abdominal quadrant. Sonography showed a 58 mm mass anterior to the uterus and adjacent to the ovary, probably a uterine myoma. Laparotomy revealed normal uterus, and ovaries with a translucent mass originating from the appendix and fixed to the cecum. Pathologic examination of the mass was reported as low grade appendiceal mucinous neoplasm.

This is a rare case of appendiceal mucocele in a young female, mimicking a pelvic mass, which was misinterpreted by sonography as a gynecologic solid mass near the uterus. Preoperative diagnosis of appendiceal mucocele is important due to the risk of concurrent GI and ovarian malignancy associated with the condition.

The objective of this study was to compare clinical findings and inflammation indicator levels between total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH) in an instructional setting.

In this prospective study, 80 total hysterectomy procedures were performed at the gynecology clinic of Imam Hossein Medical Center, Tehran, Iran over the period between January 2017 and October 2019. Patients were divided into two groups according to the type of operation. Forty patients underwent TLH (TLH group) and 40 patients underwent TAH (TAH group). Surgery-related outcomes and inflammatory mediators were both assessed before and 24 hours after the surgery. 

We observed significantly lower operation bleeding (P <0.001), postoperative lower c-reactive protein (CRP) (P <0.001), higher length of surgery (P <0.001), and higher anesthesia duration (P <0.001) in TLH group compared to TAH group. There were no statistically significant difference between groups regarding post-operation transfusion, adverse events, polymorphonuclear leukocytes (PMN) count, white blood cell (WBCs) count  and platelet (PLT) count, as well as the homoglubin (Hb) levels.

Our study results show that the TLH can be safely performed in our instructional setting and it decreases intraoperative bleeding and postoperative day one CRP levels compared to the TAH method.

 Osteoporosis might result in an increased risk of bone fracture. Diagnosis of osteoporosis results in proper treatment and reduction of fracture rate.

 This study aimed to construct a predictive model of osteoporosis case finding in Iranian women.

 A prospective diagnostic value study was designed, enrolling 317 asymptomatic women 50 years old or more referred for screening, at the Imam Hossein Medical Center, Tehran, Iran, for two years. The data was collected with the census method. A questionnaire including risk factors was completed, and bone mass densitometry (BMD) was done by the dual-energy X-ray absorptiometry (DXA) method in all cases. According to standard curves, bone density of the femur and lumbar spine clarified osteoporosis status for each person. In the first step, univariate analysis with osteoporosis as the main outcome did use the chi-squared test, independent sample t-test. In the next step, factors with a P-value of less than 0.2 were included in the multivariate logistic model, and a predictive model was constructed. The goodness of fit test was applied to assess the model building. The area under the curve (AUC) calculated for the model and the best cut-point for risk of menopause according to the Youden index were determined. The significance level was set at 0.05 for statistical analysis. Statistical analyses did use the program SSPS version 17.0 (SPSS, Inc., Chicago, IL, USA).

 In 317 cases of the present study, the mean age of the population was 52.46 years old. Ninety-nine (%31.2) of these asymptomatic women revealed osteoporosis on the BMD test. Age and family history of osteoporosis were risk factors, and BMI, parity, and menopause age were protective factors for osteoporosis. Constructed model of osteoporosis prediction was as follows: (age × 0.149) + (family history × 0.963) - (BMI × 0.088) - (menopause age × 0.097) - (parity × 0.80). Optimal cutoff = 0.336 based on Youden method was chosen to predict the risk of osteoporosis.

 BMD test in Iran in more than 50 years old might find positive osteoporotic cases in at least 23.8%. BMD test in Iran in more than 50 years old might find positive osteoporotic cases in at least 23.8%. A model of osteoporosis probability constructed based on age, family history, menopause age, and parity in the present study can predict women at risk of osteoporosis.

Endometrial stromal sarcoma is a rare condition, constituting nearly 0.2% of all reproductive tract malignancies. The condition mainly affects the peri-menopausal population; however, it can occasionally be found in younger women and adolescents. Here, this is a case of a 20-year-old primiparous female who was referred to us with the main complaint of vaginal bleeding (menometrorrhagia), ongoing for 6 months after delivery. Her sonography report indicated a 5 cm intra-cavitary mass suspicious for myoma or placental polyp. Given the pathology report of low-grade endometrial stromal sarcoma (LGESS) on samples obtained through hysteroscopy and D&C, she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO). Endometrial stromal sarcoma is a rare uterine malignancy of mesenchymal origin that should be considered, even in very young patients.

Visual Inspection with Acetic Acid (VIA) is an inexpensive option for cervical cancer screening.  In this study, we evaluated the role of the VIA as well as of the clinical symptoms/signs to find the best case-finding method for Cervical Intraepithelial Neoplasia (CIN) 2+.   

In a cross-sectional study, we extracted from records the demographic characteristics, clinical symptoms/signs, and indications for colposcopy referral of patients with CIN 2+ in pathology. Patients were divided into 1- Abnormal Pap smear, 2- Positive VIA, 3- abnormal Pap smear with clinical symptoms/signs, 4-VIA positive with clinical symptoms/signs, 5- only clinical symptoms/signs. The sensitivity of each method was studied to determine their effectiveness as a screening method.  

Out of 146 patients who underwent colposcopy, 38 patients had it due to abnormal Pap smears, 37 due to positive VIA, 21 due to abnormality of both these tests, and 50 due to clinical symptoms/signs despite having normal screening tests. The sensitivity for VIA and Pap smear was 73.39% (17.48%-83.31%) and 40.41% (32.47%-48.86%) respectively. Presence of at least one of the three clinical symptoms/signs and a positive VIA found 78.8% of CIN 2+ cases. Presence of at least one of the three clinical symptoms/signs and abnormal Pap smear identified 84.2% of the cases.  

To find high-grade CIN, focused attention to the clinical symptoms/signs, even in the presence of normal Pap smear, can increase the sensitivity of Pap smear and VIA. In low resource settings, a simple, highly sensitive method like VIA can be used in addition to or as an alternative to other means.

Lower abdominal or pelvic pain is a common complaint among women and one of the most challenging findings to evaluate. We performed the present study to construct a new algorithm for predicting the chance of ovarian torsion among women with acute lower abdominal pain.

This diagnostic retrospective cross-sectional study was performed on all female individuals who were referred to Imam Hossein Medical Center, Tehran, Iran, with the chief complaint of acute lower abdominal pain, and underwent laparotomy between 2010 and 2016. Clinical and paraclinical findings were evaluated to construct a predictive model for ovarian torsion. The variables were compared in 2 groups. The first group included individuals with a final diagnosis of ovarian torsion and the second group included those individuals with any diagnosis other than ovarian torsion. All data were compared between these 2 groups using SPSS software Version 21 to find the related findings with a predictive value for ovarian torsion.

A total of 372 participants were evaluated, of whom 116 participants (31.2%) had ovarian torsion (case group) and 256 participants had other diagnoses for their lower abdominal pain (control group). Nausea and vomiting (p < 0.001), tenderness (p < 0.001), the size of ovarian mass (p = 0.004), and the percentage of polymorphonuclear (p < 0.001) showed significant relationships with ovarian torsion as the final diagnosis. Multiple logistic regression models were constructed to predict the factors affecting ovarian torsion, and a scoring system was designed to predict ovarian torsion, with a sensitivity of 77.59% (68.9%- 84.8%) and specificity of 74.61% (68.8% 79.8%).

The proposed model is suitable for predicting ovarian torsion and its necessary information is readily available from individuals’ history, examination findings, laboratory results, and an ultrasound exam.

The effectiveness of cervical cancer screening programs is an issue of concern in developing countries. It  is a goal of researchers to find another solution or screening method to solve this problem. The current study aimed to compare the cos teffectiveness of the colposcopy and HPV-Pap test approaches.  This cross-sectional study examined 1944 asymptomatic women aged 30-70 years who had undergone colposcopy from 2013-2015. The cost of finding each CIN2 case was obtained and compared with the cost of the HPV-Pap test finding.  A pathology of CIN2  or greater cases were reported in 43 cases (2.2%). The cost of finding each case by colposcopy was 2,456 USD and by PCR-Pap was 2,966 USD (P<0.0001). The cost of finding each CIN2 or greater case by HPV-Pap test was 1.32 times that of a colposcopy. Colposcopy in this setting was more cost-effective and should be considered in similar settings.

Ectopic pregnancy (EP) is considered a main reproductive health challenge. According to the side effects of using methotrexate (MTX), it is rational to find safer drugs in the management of EP. This randomized controlled trial aimed to evaluate the efficacy and safety of adding letrozole to the single-dose MTX in the management of EPs. This study was conducted in an academic hospital affiliated to Tehran University of Medical Sciences. Women with EP and stable vital signs with β-hCG levels ≤3500 were assigned randomly to receive MTX + placebo or MTX + letrozole. The regression pattern of β-hCG, need for further surgery, and potential side effects were compared between groups. A total of 90 women were assigned equally to the study groups and were matched in age, body mass index (BMI), serum biochemistry, and primary levels of β-hCG. No drug-related side effects were observed in groups. The rates of further surgery (p = 0.614) and second dose of MTX (p = 0.809) were not significant between groups. In the MTX + placebo group, we observed a minor increase in β-hCG levels on day 4 followed by a decreasing pattern on days 7 and 14. But, in MTX + letrozole group, a decreasing pattern in β-hCG levels from day 1 through day 14 was perceived. The results support using MTX + letrozole to treat stable women diagnosed with tubal EP as a safe and efficient method. Further studies are required to evaluate letrozole alone as an alternative therapy in EPs.

Although acute appendicitis is a common problem, it remains a difficult diagnosis to establish, particularly among females of reproductive age. The present study was conducted to devise a new decision making model for diagnosing acute appendicitis in non-pregnant women.

The present study was a retrospective study consisting of women who had undergone an appendectomy between 2007 and 2015 at the emergency department of Imam Hossein Medical Center, Tehran, Iran. The inclusion criteria were being a female, presenting with abdominal pain, being a suspected case of acute appendicitis, and undergoing an emergency appendectomy. A classification and regression tree (CART) analysis was performed to partition exam and laboratory data obtained from these patients into homogeneous groups in order to develop a prediction rule for appendicitis diagnosis.

The study population included 433 non pregnant women who underwent emergency operations with a preliminary diagnosis of acute appendicis. Out of these patients, 295 patients (68.1%) were appendicitis positive based on the pathology exam results, while 138 patients had a normal appendix, indicating a negative appendectomy rate of 31.8%. The final devised CART model included hemoglobin level, PMN count, age, and history of abdominal incision and yielded a sensitivity of 82.7% and specificity of 55.8%, which were better than Alvarado prediction results for the Asian population.

We have devised a simple and cost effective prediction model for predicting the outcome among non-pregnant women undergoing emergency appendectomy operation with good sensitivity and specificity compared to the Alvarado model.

A variety of presentations may be manifested by retained sponge, including intestinal obstruction, intestinal fistula, malabsorption syndrome and chronic pain from adhesions; in some cases, it may have an asymptomatic clinical course.

Case report:

 In a 41-year-old female, gravida 4 para 4, with a history of laparotomy performed for an ovarian adenocarcinoma three years prior to her referral, a gossypiboma was incidentally detected on follow up imaging. The gossypiboma was safely excised by a midline laparotomy.

Asymptomatic gossypiboma should be considered in patients presenting with a mass, who have undergone laparotomy in the past.

This was a report of uterocutaneous fistula as a rare complication of expectant management of placenta increta, and a review of the literature..
A 38- year- old pregnant woman in her third term of pregnancy was operated on in a secondary hospital in Arak (a city located in the center of Iran) in April 2015. As a result of placenta incereta, the attached placenta was left in the uterus. On the 38th day, she was referred to our tertiary care hospital due to intermittent fever and bleeding. More examinations by MRI and hystrosalpingography revealed uterocutaneous fistula. She was operated on again, and surgical findings indicated coexistent uterine necrosis and uterocutaneous fistula..
This case was the first reported morbidity of fistula in the uterocutaneous pathway..

Uterine leiomyomas are the most common benign solid tumors of the female pelvis. Retroperitoneal myomas are extremely rare and usually malignant with the common location being in the pelvis.
Our case involved a woman who was suffering from dysparonia and radiculating right pelvic pain. The pelvic examination revealed a palpable tender mass of about 3-4 cm in size in the right adnexa near the pelvis bone. An orthopedic consultation was in favor of the mass being of gynecologic origin. A retroperitoneal approach on the right side revealed a 3 cm mass in the right obturator fossa.
The most common place for a myoma is in the uterus. However, other sites have also been presented as case reports. Most smooth muscle tumors originating in the retroperitoneum are malignant. Retroperitoneal sites for myomas are mostly in the pelvis (73.1%). The frequent symptoms of retroperitoneal masses, including myoma, are discomfort, fatigue, weight loss, and radiating pain. The common sonographic findings in these patients is a pelvic solid mass with heterogeneous features. Surgical excision is the main treatment of retroperitoneal smooth muscle tumors.

Background and Determined outcomes in education are based on the ultimate expectations from the medical graduates.
One hundred and two medical school graduates of the last 4 years of universities located in a city were asked in 2015 to self-evaluate themselves according to 42 expected skill outcomes. These 42 procedures were approved in 2007, by expert panels of Iranian Ministry of Health and Medical Education.
Mean score of 42 procedures according to self-evaluation in overall respondents (n=102) was 11.5±2.1. Just in 31% (13 out of 42 procedures), the scores were in the acceptable range of above 15.
Graduates evaluate themselves weak in 69% (29 out of 42 procedures). If their self-evaluation is real, clarifying the causes might be a key to educational improvement.

Placenta accreta is an increasingly common complication of pregnancy that can result in massive hemorrhage.
We describe two cases of placenta accreta, with successful conservative management in a referral hospital in Tehran, Iran. In both cases, two procedures were performed: compression suture (B-Lynch) and a perfusion-decreasing procedure (bilateral uterine artery ligation). We also present the results of a narrative literature review.
The double B-Lynch and uterine arterial ligation procedure in cases of abnormal placentation might be strongly considered in fertility preservation, coagulopathy, coexisting medical disease, blood access shortage, low surgical experience, distant local hospitals, and no help.

In review of medical education literature there are seven main categories of learning theories. This review has aimed to summarize them. Different learning theories include adult learning theories (Andragogy), behaviors orientation, cognitivist orientation, humanist orientation, social learning orientation, constructivist model and transformation learning. In conclusion, in medical education and its theories bases should effectively include all of these aspects in order to train competent graduates.