shahrzad sheikh hasani

Ovarian cancer is the second most common malignancy in women worldwide, causing many deaths each year. Chemotherapy is one of the most important therapeutic strategies that can increase the survival of these patients; however, one of the problems in chemotherapy is resistance against platinum treatment. Evaluating the effect of platinum- and non-platinum-based chemotherapy in patients with recurrent platinum-resistant ovarian cancer can enhance our view on this issue. The present review article sought to identify the treating efficacy of platinum and non-platinum-based chemotherapy in patients with recurrent platinum-resistant ovarian cancer by searching scientific databases and examining the aspects of platinum resistance in various articles. Oncological results have shown that ovarian cancer is a deadly disease, and most cases are diagnosed when the cancer spreads outside the ovary and often throughout the entire abdomen. On the other hand, in many cases, disease recurrence is associated with drug resistance. The use of a platinum-free interval has played an important role in its treatment efficacy. Understanding the cause of platinum resistance and discovering strategies to reduce drug resistance, especially to new ones, is very important. The present article suggested oncology teams agree on treatment methods and the best treatment approach against platinum resistance in malignant ovarian cancers and offer a better treatment solution by considering innovative strategies.

Pregnancy after a heart transplant is a concern for many female recipients, and it remains a medical challenge that raises many questions. A 24-year-old woman, gravida 3, para 0, contacted us for obstetric care in the first trimester of gestation, about 3 years after an orthotopic cardiac transplant. She was a known case of dextrocardia with congenitally corrected transposition of the great arteries. The transplant had been performed for severe retractable heart failure, manifesting during her previous lost pregnancy. The course of the current gestation was uneventful. The patient’s cardiovascular function was good throughout the pregnancy. She was admitted to the hospital for dyspnea at 35 weeks and 4 days of gestational age. A cardiovascular consult and echocardiography were performed. The results were within the normal range, and labor pains explained the patient’s dyspnea. Because of labor pain, a repeat Cesarean section was performed at 35 weeks and 4 days of gestational age. A male baby weighing 2700 g, with an Apgar score of 7/9, was delivered. The patient was discharged after delivery with enoxaparin (40 mg), prednisolone (5 mg), levothyroxine, and mycophenolate mofetil (500 mg) without any complications. Follow-up was carried out at 1 month, and no abnormality was found. Here, we report a case of a successful pregnancy in a young woman after a heart transplant.

Endometrial hyperplasia is the irregular proliferation of endometrial glands and an increase in the ratio of gland to stroma compared to normal proliferative endometrium. Endometrial hyperplasia is one of the precursors of endometrial cancer, which is one of the most common cancers among women. The present study was conducted with the aim of investigating changes in the expression level of FOXO1 and P27 kip genes in endometrial hyperplasia tissue samples compared to normal tissue sample. In this case-control study, samples of hyperplasia with normal marginal tissue were taken from the uterine endometrium of women who referred to the women's clinic of Arash Hospital with abnormal uterine bleeding or increased endometrial thickness. Marginal normal tissue sample and hyperplasia sample were considered as control and case, respectively. The relative expression level of FOXO1 and P27 kip genes was measured by real time PCR method after total RNA extraction and cDNA synthesis, and then the data obtained from the reaction was analyzed by RQ=2-ΔΔCT method. Data were analyzed using independent t-test. The relative expression level of FOXO1 and P27 kip genes in the hyperplasia tissue sample was not significantly different compared to the control group (P>0.05.( Although the results of some studies indicate that the expression level of FOXO1 and P27KIP genes can be changed in endometrial cancer, the results of the present study showed that, contrary to expectations, there is no significant change in relative expression level of FOXO1 and P27KIP genes in hyperplasia tissue compared to normal tissue.

Methotrexate (MTX) and actinomycin D (ActD) have been used as first-line chemotherapy agents in the treatment of low-risk gestational trophoblastic neoplasia (GTN). Although low-risk GTN is considered a curable disease, its reported primary remission rates of 49 to 93% reflect the difficulties of treatment and different factors influencing it. Hence, this study aimed to determine the remission rates and related factors of single-agent chemotherapy resistance in low-risk GTN patients.

This retrospective study included patients with diagnosed low-risk GTN who received either MTX once a week (IM, 30mg/m2) or ActD once every two weeks (pulsed IV, 1.25mg/m2). Then, the patients were followed-up until complete remission or single-agent treatment failure to assess resistance rate and related factors.  

Eighty-four patients were included in the study (18 patients were receiving MTX and 66 patients were receiving ActD). 85.7% of all participants achieved complete remission after first-line chemotherapy (72.2% in MTX vs 89.4% in ActD). There was a significant association for higher tumor size (P=0.046), the occurrence of metastasis (P=0.019), and pretreatment β-HCG levels (P=0.005) with resistance to treatment.

This study demonstrated higher tumor size, the occurrence of metastasis, and pretreatment β-HCG levels have been associated with increased resistance to first-line chemotherapy agents.

More than 75% of epithelial ovarian cancer (EOC) cases are diagnosed in advanced stages, which is associated with tumor recurrence and chemotherapy resistance. So far, to the best of our knowledge, a similar study has not been conducted in Iran to investigate the clinical characteristics and survival rate of these patients treated with neoadjuvant chemotherapy (NACT).

This study aimed to evaluate the clinical characteristics and survival of patients treated with NACT followed by cytoreductive surgery and the factors affecting survival.

This retrospective cohort study was conducted on 147 advanced ovarian cancer cases who were treated with NACT referring to the Gynecology Oncology Department of Imam Khomeini Hospital in Tehran, Iran, between 2011 and 2021 and met the inclusion criteria for this study. The survival curve and Cox regression method were used to analyze the data.

The results revealed that 8.9% of advancedEOC (147/1,650) were treated with NACT and the average number of NACT courses was 4.12 periods. The survival rates of 1, 3, 5, and 8 years were 85.31%, 44.05%, 18.35%, and 13.77%, respectively. The mean and median of survival time were 47.7 and 36 months,respectively. Nearly 80% of the patients had stages 3C and 4A before receiving NACT. Based on the results of the adjusted Cox regression model, tumor marker level showed a significant relationship with survivalrate (P=0.008), and also peritoneum involvement had a clinically significant impact on survival with a hazard ratio of 2.88.

The results suggested that8.9% of ovarian cancer cases were treated with NACT. It was also revealed that the average number of NACT courses was 4.12 periods and the 8-year survival rate was 13.77%. CA125 tumor marker level showed a significant relationship with survival rate, and peritoneum involvement had a clinically significant impact on survival.

Cervical cancer is one of the most common cancers in women. One of the most important indicators that deal with all aspects of the patients' health is the Health-related quality of life (QOL). In this study, the QOL of women with cervical cancer in Iran was investigated.

The present cross-sectional study examined the QOL of 139 patients with cervical cancer referred to Imam Khomeini hospital, affiliated with the Tehran University of Medical Sciences. For this study, a specific questionnaire of QOL in patients with cervical cancer was used. To determine the predictors of cervical cancer patients, the QOL linear regression model was used.

 Findings of this study showed that the total score of QOL of patients was 20.97±1.29. Moreover, in the regression model, a significant relationship was observed between the type of treatment and patients' QOL scores and those patients who had neoadjuvant therapy plus surgery (β=-17.45, P=0.02) and those who received brachytherapy (β=- 14.86 and P=0.09) had a significantly lower QOL score.

Overall, the QOL of people with cervical cancer was moderate. Implementing educational programs for service providers and choosing the appropriate type of treatment according to the stage of the disease and the patient's age can help control this type of disease and its complications and improve the QOL of patients.

Although ovarian cancer is the sixth most common cancer among women, in most cases, it is not diagnosed until it covers the entire peritoneum. In the present study, it was examined the clinical outcomes of the women with epithelial ovarian cancer (EOC) in stage IIIC-IV treated with neoadjuvant chemotherapy (NACT) and its association with decreased ovarian cancer antigen (CA-125).

In this cross-sectional study, 78 women with EOC (Stage IIIC-IV) who underwent NACT at Imam Khomeini hospital, Tehran, Iran were evaluated. Demographic characteristics, aged at diagnosis, severity and stage of disease, serum CA-125 level, histological type, tumor pathology before and after chemotherapy, overall survival, and recurrence of disease was examined.

In total, 78 women with mean age of 52.83 ± 10.18 (between of 29 to 77) years were evaluated. The majority of the patients had positive initial ascitic fluid cytology for malignancy (68.9%). After surgery, papillary serous was the most common histologic finding (73, 81.1%). CA-125 level post NACT (median of 25 U/mL) was significantly reduced compare to before NACT (median of 980 U/mL; P<0.0001), and the rate of CA-125 reduction was significantly lower in older participants’ ages (r=0.274, P=0.017). Survival time showed a significant and strong negative correlation with the CA-125 levels before (r=-0.363, P=0.003) and after NACT (r=- 0.383, P=0.002). Moreover, there was a significant negative correlation between survival time and chemotherapy courses (r=-0.363, P=0.003) and age (r=-0.474, P=0.000).

The results of this study showed that the clinical outcomes of patients with advanced ovarian cancer can be predicted by a decrease in serum CA-125 levels after NACT.

Perivascular epithelioid cell tumors (PEComas) are a group of mesenchymal neoplasms with different biological presentations from benign to malignant types. Hence, we report the first description of PEComa presenting with an acute surgical abdomen. Her definite diagnoses were made based on the histomorphology results at Imam Khomeini Hospital, Tehran University of Medical Sciences, in 2020.
Considering different clinical presentations, unknown characteristics of imaging, and rarity of PEComa, preoperative diagnosis of it seems impossible. However, IHC can play an important role in its diagnosis.

Due to its rarity, the standard clinical presentation, treatment protocol, and prognosis of primitive neuroectodermal tumor (PNET) have not been clearly described yet. Hence, herein we reported a case of ovarian peripheral PNET whose histomorphology reports caused her certain diagnoses at Imam Khomeini Hospital, affiliated to Tehran University of Medical Sciences, Tehran, Iran, in 2020.Considering different clinical presentations, and poor prognosis of PNET compared to other ovarian malignancies, to on-time diagnosis and treatment, the patient's histomorphology and immunohistochemical (IHC) profile assessment, particularly in younger women, seems beneficial.

We aimed to evaluate treatment responses and recurrence rate of atypical endometrial hyperplasia (AEH) and endometrial endometrioid adenocarcinoma (EA) with Stage IA Grade 1 to megestrol in Iranian patients who are candidates for medical treatments.

In a retrospective cohort study that was conducted on 50 patients with AEH and 22 patients with EA who were referred to the oncology clinic of Imam Khomeini Hospital, Tehran, Iran, during 2006–2016, we recruited all patients with AEH or EA of Stage IA Grade 1 and their disease was diagnosed during endometrial curettage with or without hysteroscopy. Patients were initially treated with 160 mg of megestrol daily, along with aspirin up to 3 months, and then after 3–4 weeks of discharge of the drugs, patients underwent curettage with hysteroscopy.

The patients with AEH had 31 complete responses and five progressive diseases, and the patients with EA had seven complete responses and seven progressive diseases. After treatment, 25 cases with AEH and 5 cases with EA had an intention to get pregnant, whereas eight patients with AEH and 1 case with endometrial cancer became pregnant. Recurrence occurred in the 2 cases with AEH and 2 cases with endometrial cancer which the time of recurrence in the patients with AEH was longer than in patients with endometrial cancer (P = 0.011).

Megestrol is an effective therapeutic agent in endometrial hyperplasia or low-grade endometrial cancer patients who are willing to conserve their childbearing.

In recent years, before radical hysterectomy, neoadjuvant chemotherapy (NACT) has been administered to patients with locally advanced cervical cancer to shrink large tumors. It has been reported that this treatment significantly reduces the need for radiotherapy after surgery. The current study aimed to assess the outcome (survival, recurrence, and the need for adjuvant radiotherapy) of locally advanced cervical cancer in patients treated with NACT followed by radical hysterectomy and primary surgery.

In a retrospective cohort study, the records of 258 patients with cervical cancer (stage IB2, IIA, or IIB), who referred to Imam Khomeini Hospital (Tehran, Iran) from 2007 to 2017 were evaluated. The patients were assigned into two groups; group A (n=58) included patients, who underwent radical hysterectomy and group B (n=44) included those, who underwent a radical hysterectomy after NACT. The outcome measures were the recurrence rate, five-year survival rate, and the need for adjuvant radiotherapy.

The median for overall survival time in group A and B was 113.65 and 112.88 months, respectively (P=0.970). There was no recurrence among patients with stage IB2 cervical cancer in group B, while the recurrence rate in group A was 19.5% with a median recurrence time of 59.13 months. Lymph node involvement was the only factor that affected patients’ survival. The need for postoperative adjuvant radiotherapy in group B was lower than in group A (P=0.002).

NACT before the hysterectomy was found to reduce the need for postoperative radiotherapy in patients with locally advanced cervical cancer according to disease stages. As a direct result, adverse side effects and the recurrence rate were reduced, and the overall survival rate of patients with stage IIB cervical cancer was increased.

The aim of this study was to determine the 3-year overall survival among the epithelial ovarian cancer patients based on the histology, age, and the stage of the disease in Iran during 2011-2017.

This study was a cross-sectional retrospective study that was conducted on 179 newly diagnosed patients with epithelial ovarian cancer, who had referred to the gynecologic cancers clinic in a referral training hospital in Tehran during 2011-2017. The patients’ data including the demographic characteristics of the patients, the stage of the disease, and the treatment type were analyzed based on the pathologic responses.

Among 220 newly diagnosed patients with epithelial ovarian cancer, 179 of them were suitable for the follow-up. There were 93 death and 85 living cases among these patients and the mean age of the patients was 50.5 ± 11.3. In addition, most of the patients were in stage 3 (60.9%) and 6.7% of them were in stage 4. The most common pathology was serous adenocarcinoma (70.9%). In this study, the overall survival rate had no connection with the type of tumor histology but it was related to the stage of the disease (P=0.05). Finally, there was no mortality in stage one and among the mucinous adenocarcinoma cases.

The survival in the epithelial ovarian cancer was related to the stage of the disease and among all the pathologies, mucinous adenocarcinoma and clear cell carcinoma had the best survival rate.

Choriocarcinoma and placental site trophoblastic tumor (PSTT) are rare varieties of gestational trophoblastic disease (GTD). PSTT alone constitutes about 1-2% of all trophoblastic tumors, which presents at early reproductive age and the serum beta-hCG level is much lower than choriocarcinoma. This tumor usually invades the myometrium and its depth of penetration is a prognostic factor. The first case report is regarding a 33-year-old woman with vaginal bleeding 3 months after abortion. The ultrasound exhibited heterogeneous and hypervascular mass related to previous cesarean scar. Serum beta-hCG level was 67 mIU/ml and chemotherapy was administered. However, due to severe vaginal bleeding and no regression in mass size, total abdominal hysterectomy was performed. Histopathological examination and IHC staining confirmed PSTT from previous cesarean section. The second case report is regarding a 33-year-old woman with cervicoisthmic choriocarcinoma, which was mistaken as cesarean scar pregnancy. The ultrasonography and elevated serum beta-hCG level suggested cesarean scar pregnancy. The patient was treated with methotrexate without any effect. Eventually, cervicoisthmic choriocarcinoma was detected after hysterectomy. A diagnostic error was made leading to possible uterus perforation along with incorrect chemotherapy that resulted in a life-threatening condition. It is concluded that PSTT and choriocarcinoma are the two important differential diagnoses of sustained elevated beta-hCG when imaging evidence is also suggestive. Although PSTT and cervicoisthmic choriocarcinoma are rare, they do exist and are on the rise.

Introduction:

 Timely diagnosis of gestational trophoblastic neoplasia (GTN) is essential for successful management of the condition and preservation of fertility. The aim of the present study was to describe a case of misdiagnosis GTN with brain and lungs metastasis.

Patient information :

the present case study was conducted in Imam Khomeini hospital, Tehran, Iran, in 2017. A 35-year-old woman presented with acute headaches and left hemiplegia one month after the conclusion of her term pregnancy. The patient was previously diagnosed as a case of subarachnoid hemorrhage and inferior sagittal sinus thrombosis and was unsuccessfully treated with anticoagulant drugs leading to worsening signs and symptoms. Her initial β-hCG at admission to the hospital was 22,000,000IU/L, which lead to diagnosis of GTN with extensive metastatic lesions in the lungs and brain. Due to extensive intracranial hemorrhage, the patient was first treated with whole brain radiation therapy for 10 sessions daily (Total Dose=3000cGy). EMA-EP treatment was initially withheld due to concern for bleeding during concurrent radiation therapy. Following the brain radiation therapy, the chemotherapy was started for the patient. Upon completion of 3 cycles of EMAEP, the patient’s hCG was lowered to 5IU/L. The treatment was continued for 5 more cycles and resulted in hCG reading of under 2IU/L at her last visit.

Conclusion :

This case highlights the variable presentation of GTN which might easily cause misdiagnosis and delayed treatment and shows excellent response to treatment despite late treatment and massive tumor burden with some modifications to plan of treatment

Uterine sarcomas comprise a group of rare tumors with different tumor biology, natural history and response to treatment, contain just 3-7% of total uterine malignancies and about 1% of all gynecologic cancers. Although they cause important part of women death due gynecologic cancers. These tumors have aggressive behavior and high recurrence rate, even when confined to the uterine corpus at the time of diagnosis. The most common of uterine sarcomas is leiomyosarcoma. The incidence of leiomyosarcoma is increased after age 50. Traditionally, carcinosarcomas were named as Malignant Mixed Mullerian tumor (MMMT), but in recent classification according to their pathologic structure and its behavior, these tumors are classified as carcinomas. The rare group of sarcomas is endometrial stromal sarcoma (ESS), which occurres in younger women. In a medical studies search from 2000 to 2017, all kinds of uterine sarcomas, pathologic diagnostic methods, primary treatment and supportive treatment have been analyzed. Last histological classification is based on FIGO 2009 and WHO. According to such classification, sarcomas divided into three subtypes: leiomyosarcoma, endometrial stromal sarcoma and carcinosarcomas. Diagnosis of sarcoma before treatment and discrimination from benign myoma by current diagnostic methods is difficult. Preoperative endometrial sampling identifies only 25% of sarcomas. It may be the myometrial origin of tumor. Currently, MRI, ultrasound and PET scan may be used for the diagnosis of tumor. The gold standard of treatment is complete and intact resection of tumor considereing free margins. In advanced or recurrence disease, cytoreductive surgery followed by chemotherapy is the choice of treatment. If technically it is not possible or there are extra abdominal metastases, palliative chemotherapy should be considered. Combination of gemcitabine and docetaxel is an acceptable choice. Recent studies are going to approve the effective role for targeted agents with or without cytotoxic chemotherapy in these group of aggressive tumors. The only drug in this group has approval is pazopanib. However, it did not achieved acceptable responses in phase I, II studies. As regards of tumor biology and inappropriate response to chemotherapy and radiotherapy, sarcoma have poor prognosis in all stages.

Epithelial ovarian cancer (EOC) is the fifth leading cause of cancer death in women. Primary surgery, followed by adjuvant chemotherapy is the basis of treatment for this disease. A standard treatment includes primary surgery and if possible optimal debulking surgery (tumor residue of <; 1 cm), followed by a chemotherapy; paclitaxel-carboplatin is the standard regimen in ovarian cancer. Given that the main method of spreading this disease is in the peritoneal cavity, the systemic chemotherapy brings about numerous complications; moreover, as the method of prescribing a drug inside the peritoneum causes a high drug concentration in the peritoneal cavity, conducting an intraperitoneal chemotherapy has been examined clinically. In cases of ovarian cancer recurrence, performing a secondary cytoreductive surgery, in addition to hyperthermic intraperitoneal chemotherapy (HIPEC), has led to a good survival among patients. Currently, studies are ongoing to better explain the effects of this treatment method compared to previous methods.

Synovial sarcoma of the ovary is a very rare tumor reported only once in the past. It is the second softest tissue mass after rhabdomyosarcoma in adults but its usual site is extremities not ovary.

Here we describe a 53-year-old woman with primary synovial sarcoma of the ovary with insufficient treatment and lung metastasis of the tumor.

Because of harmlessness symptoms, it is usually missed and correct treatment is delayed. When facing this type of tumor, referring to well-equipped centers with experienced surgeons in this field is recommended for sufficient treatment and best results.

The incidence of vulvar cancer is nearly 5% of all gynecologic malignancies and almost 95% of vulvar cancers are squamous cell carcinoma (SCC). Recurrence is possible in 4 ways: local, regional, pelvic, and distant. In a cohort of 391 patients with vulvar SCC, distant metastasis was reported 5% .The common sites of distant metastasis are pelvic nodes, lung, and liver. Both skin and bone metastasis are rare in vulvar SCC.

The current report presented a 58-year-old female with the diagnosis of vulvar SCC. She was the 11th cutaneous metastasis, 13th bone metastasis, and the 1st case with simultaneous bone and skin metastasis reported in the last 60 years.

It is necessary to consider any lesion on the vulve, especially inmenopause females, and it should be the low threshold for biopsy to avoid delay in detection. After completion of selective treatment, the exact follow-up should be considered to discover metastases.

One of the rare ovarian neoplasms is sclerosing stromal tumor (SST). The most common age at presentation of sclerosing stromal tumor is the second and third decades of life. Usually this tumor presents with menstrual irregularity and pelvic pain as reported previously. Surgery is mandatory for diagnosis because there is not any distinctive feature to diagnose by imaging techniques.

Our case in this report is a 26-year-old woman presented with pelvic pain. We conducted routine laboratory tests and checked ovarian mass tumor markers preoperatively. Due to her normal hormonal status in physical examination, we did not request more hormonal laboratory tests. However on imaging, we did not suspect benign tumor. Doppler sonography showed low resistance flow in peripheral and center of the mass. Right ovarian mass was resected and diagnosed as ovarian stromal tumor compatible with sclerosing stromal tumor. Unexpectedly at operation, we encountered severe hemorrhage from peritoneal surface so that conservativemanagement such as packing and suturing or cauterization was not helpful. Finally, argon coagulation stopped bleeding. All coagulation laboratory tests requested by a hematologist were normal.

In conclusion, we believe that vascular endothelial growth factor (VEGF) production of tumor is responsible for massive bleeding.