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Prezentare de caz şi revederea literaturii Sex cord-stromal tumors of the ovary: granulosa-stromal cell tumors. Materials and method. This paper describes a case of granulosa tumor cell, juvenile type, in a young woman with secondary amenorrhea and primary infertility.

Granulosa tumor cell, juvenile type, was suspicioned after clinical and paraclinical tests had been done, and MRI de­scribed the ovarian tumor. This case emphasizes the importance of multidisciplinary team approach, involving gynecologist, fertility specialist, oncologist, and radiologist.

We have reviewed the available literature in this report. Although most cases are treated with surgery alone fol­lowing oncological safety endometrial cancer recurrence rates as in epithelial ovarian cancer approach, it is important to discuss the follow-up ap­proach, taking into consideration that this patient par­ti­cularly wished to procreate, and fertility sparing surgery was performed.

Chemotherapy and radiotherapy were com­plementary treatments that were discussed in the multidisciplinary meeting, but as no adjuvant therapy was found to be effective, these adjuvant therapies are kept for recurrence and palliative care for advanced disease.

Given the rarity of this disease worldwide, it is important to raise awareness amongst medical staff and educate the general population to seek medical attention early.

Keywords sex cord-stromal tumors of the ovary, granulosa tumor cell, juvenile granulosa tumor cells, fertility sparing surgery, ovarian cancer Rezumat Introducere.

Materiale şi me­­to­­dă. Lu­crarea descrie un caz de tumoare de gra­nu­loasă endometrial cancer recurrence rates tip juvenil la o femeie tânără cu amenoree se­cun­dară şi infer­ti­­li­­tate primară. Tumoarea de granuloasă de tip ju­­ve­nil a fost suspicionată după ce s-au efectuat investigaţiile endometrial cancer recurrence rates şi paraclinice, iar RMN-ul a descris o tumoare ovariană. Ca­zul prezentat arată im­por­tanţa abordării în echipă mul­ti­­dis­­ci­pli­nară care să in­clu­dă ginecologul, specialistul în re­pro­du­­ce­re medicală asis­ta­tă, oncologul medical şi spe­cia­lis­tul în ima­gis­tică.

Deşi tra­ta­mentul de papillomavirus lingua sintomi îl reprezintă chi­rur­gia, cu res­pec­tarea prin­ci­piilor de siguranţă oncologică si­mi­lare celor din can­ce­rul epitelial endometrial cancer recurrence rates, este importantă in­di­vi­dualizarea tra­­ta­­men­­tului la pacientele care doresc con­ser­va­rea fer­ti­li­tă­ţii, situaţie în care se recomandă o chirurgie adaptată aces­tui deziderat.

Chimioterapia şi radioterapia sunt tra­ta­mente com­ple­mentare, recomandate în caz de recidivă sau paliaţie, în stadii avansate de boală. Datorită rarităţii acestor endometrial cancer recurrence rates, este necesară o continuă in­for­mare a po­pu­laţiei feminine şi a medicilor de familie de a so­li­cita opinia spe­cia­listului pentru o depistare precoce.

Cuvinte cheie tumoare ovariană stromală de cordoane sexuale tumoare cu celule granuloase tumoare juvenilă cu celule granuloase chirurgie conservatoare a fertilităţii cancer ovarian Introduction Sex cord-stromal tumors of the ovary SCSTO is a group of ovarian tumors, either benign of malignant, that usually develop from the division of the cells which surround and support the oocytes, and they include cells that produce hormones. The majority of the malignant SCSTO have a good prognosis, being diagnosed in an early stage, and they are low-grade malignancies compared with epithelial ovarian cancer.

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Pre- or postmenopausal women account the same percentage of granulosa stromal cells tumors 2. Patients with these types of tumors usually have signs and symptoms of estrogen and androgen excess.

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Granulosa cell tumors are part of the group of sex cord-stromal tumors of the ovary, being the most common one and having a malignant potential 3.

These tumors are large ovarian masses, up to 15 cm 4.

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The juvenile type is very rare, and this is specific for children, for women at puberty, or in their early 20s. This subtype seems to be more aggressive, with early recurrence compared with the adult subtype, that tends to have endometrial cancer recurrence rates risk of late recurrence 5. In postmenopausal women, estrogen secretion can be sufficient to induce the development of endometrial cancer.

Very rare granulosa cell tumor could rupture and produce hemoperitoneum. Very rare granulosa cell tumor may produce androgens and induce virilization 8. The phenotype of the patient who develops granulosa tumor cell is non-white, obese patients with family history of ovarian cancer or breast cancer. Smoking, parity and the use of contraceptive pills seem to have a protective role in developing these types of tumors 4.

However, a gene mutation was found to be the constant in the adult type of granulosa cell tumor, and this is mutant FOXL2 9but no family cases were found.

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Surgical approach as a first-line treatment brought significant benefit on a long-term prognosis, endometrial cancer recurrence rates most of these tumors are confined with one ovary and they can be resected with oncological safety principles followed. Moreover, chemotherapy is less needed, although recurrent disease usually responds poorly to chemotherapy.

Taking into consideration that patients are in an early stage at diagnosis and surgery is usually done with a curative approach, these bring excellent prognosis and outcome for these patients, but the real prognosis and the natural history are poorly known and understood since these tumors are very rare in the population.

Clinical and paraclinical investigations Early puberty, secondary amenorrhea and endocrinologic symptoms are the most common symptoms that brings the patients to medical advice and lead to early diagnosis Other nonspecific symptoms include abdominal pain and enlargement of the abdomen for the juvenile type. For the adult type, symptoms and signs include menometrorrhagia or postmenopausal bleeding, virilization, abdominal pain and a palpable mass Blood tests and hormonal profile should be included in the investigation panel in order to check for the level of testosterone and androstendione.

Endometrial cancer recurrence rates these tumors are very rare, the hormonal profile is not evaluated currently preoperatively, therefore after surgery the levels of these hormones are normal.

Inhibin B is very accurate as a tumor marker, more specific than inhibin A, and is also useful to monitor recurrence. It was supposed that CT or MRI could characterize more accurate these tumors and bring more information than ultrasound, but the imaging features are nonspecific and cannot discriminate from the epithelial ovarian tumors Figure 1.

Ultrasound aspect of granulosa tumor cell As a diagnostic procedure, a complete surgical resection and staging are recommended for these cases. Only histopathology can diagnose adequately these tumors and can discriminate between epithelial ovarian tumors, germ cell tumors or other cancer 13 Figure 2, Figure 3.

Figure 2. Granulosa tumor cell histo­pathology HE staining The natural history of these tumors is different from that of epithelial ovarian cancers, since these tumors have a low malignant potential.

When this happens, these tumors relapse as an abdomen or pelvic mass, and bone metastases are rare as well 14, The histopathological results describe a macroscopically cystic mass, with solid or hemorrhagic content or gelatinous fluid. Treatment The treatment with the best outcome for these tumors is the complete surgical resection, with an excellent prognosis for stage I disease.

These tumors have a poor response to chemotherapy and radiation therapy, therefore surgery is not just a diagnostic procedure, but aims to resect completely the disease. When planning surgery, fertility sparing surgery should be considered especially for patients who have not completed their family and wish to preserve fertility.

Otherwise, for postmenopausal women, hysterectomy with bilateral salpingo-oophorectomy is recommended. Because of the risk of hyperplasia of the endometrium and adenocarcinoma, a risk due to estrogen exposure, it is recommended to advise the patient about endometrium sampling.

Adding lymphadenectomy as a staging procedure did not show any survival benefit. Laparoscopy used for staging did not show any specific benefit, the laparotomy approach being the chosen way to remove completely the tumor. Follow-up is done as a clinical exam, pelvic ultrasound and serum marker testing.

Chemotherapy did not show any benefit in stage I disease, however a big tumor, poorly tenă pitică la bărbat with clinical or other suspicious feature, should be discussed by the multidisciplinary team. Chemotherapy included bleomycin, etoposide and cisplatin More data is needed. However, the series is still small, taking into consideration the fact that these tumors have a very low incidence. Radiation therapy was not found useful and is usually reserved for palliative care and symptoms relief.

No change of the approach should be applied for pregnant patients and chemotherapy is more often given after papilloma cancerous. For relapse management, chemotherapy is the chosen treatment, and bevacizumab has shown to be effective. Moreover, it is expected to see a new targeted therapy, taking into consideration the gene mutation FOXL2 The prognosis of endometrial cancer recurrence rates tumors is better when compared with epithelial ovarian cancers, and depends on the stage at diagnosis, size of the tumor, completeness of surgical excision and residual disease.

Case report We report the case endometrial cancer recurrence rates a year-old woman, with a three-year history of primary infertility and secondary amenorrhea, with no other specific medical history.

The patient was admitted for a right ovarian mass discovered during a routine pelvic ultrasound. MRI was further recommended and described a right para-uterine pelvic mass, measuring up to 6 cm, with solid content and important contrast uptake. There was no right ovary structure found; the left ovary and uterus were normal; no ascites or other pathological features.

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The level of estrogen was normal. Surgical approach was decided, and a right salpingo-oophorectomy was performed. Frozen section raised suspicion of granulosa tumor cell, juvenile type. During surgery, the evaluation of uterus and contralateral ovary, peritoneal cavity and of abdominal and pelvic organs was macroscopically normal. Taking into consideration the age of the patient, the intraoperative findings and the wish to procreate, surgery was limited to a conservative approach, keeping the uterus and the left adnexa.

Postoperatively, the patient had a good recovery, with no complications, and she was discharged two days after surgery. The case was endometrial cancer recurrence rates in the multidisciplinary meeting and the patient was recommended to have close follow-up, fertility advice and pelvic MRI every three months, to check for recurrences. The first follow-up was clear, with no pathological finding on the clinical exam and pelvic MRI.

The patient is currently under the care of the infertility team in order to complete her family, and she will continue the follow-up protocol as discussed in the Menta menta meeting.

Discussion Although granulosa cell tumors are a very rare type of ovarian tumors, they have an important malignant and spreading potential, and represent the most common type of malignant ovarian sex cord tumors.

These tumors develop before puberty, and they have a higher proliferative endometrial cancer recurrence rates, but a lower late recurrence rate compared with the adult type 5.

It is important to emphasize that the juvenile type occurs in young and very young female patients, and the surgical approach should take into consideration fertility sparing techniques, informed consent and fertility advice prior to treatment. As most of the cases are diagnosed in an giardia em gatos stage, fertility sparing surgery is an achievable target and close follow-up can be a good long-term approach.

Moreover, clinical and imaging follow-up should both be part of the follow-up strategy as recurrence rate is low, but it is important to determine the recurrence very early in order to facilitate the appropriate treatment.

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Conflicts of interests: The authors declare no conflict of interests. The authors contributed equally for this article. Bibliografie Young RH. Sex cord-stromal tumors of the ovary and testis: their similarities and differences with consideration of selected problems. Mod Pathol. Gershenson DM. Sex cord-stromal tumors of the ovary: granulosa-stromal cell tumors. Available at: www. August Quirk JT, Natarajan N. Ovarian cancer incidence in the United States, Gynecol Oncol.

Advances in the Management of Cervical and Endometrial carcinoma laryngeal papillomas lesions

The epidemiology of ovarian granulosa cell tumors: a case control study. Granulosa theca cell tumors in premenarchal girls: a clinical and pathologic study of ten cases. Review of the granulosa-theca cell tumors from the Emile Novak ovarian tumor registry.

Am J Obstet Gynecol. Clinical review of the adult granulosa cell tumors of the ovary. Nonepithelial ovarian and fallopian tube cancers. In: Practical Gynecologic Oncology, 6th ed.

Mutation of FOXL2 in granulosa cell tumors of the  ovary. N Engl J Med. A nationwide study of granulosa cell tumors in pre and postpubertal girls: missed diagnosed of endocrine manifestations worsens prognosis. J Pediatric Endocrinol Metab. Patterns and progress in ovarian cancer over 14 years. Obstr Gynecol. CT and MRI finding of sex cord stromal tumor of the ovary.

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Am J Roentgenol. The utility of calretinin, inhibin, and WT1 immunohisto­che­mi­cal staining in the differential diagnosis of ovarian tumors. Hum Pathol. Retroperitoneal nodal metastasis in primary and recurrent papillomavirus treatment cell tumors of the ovary. Bone metastasis from a granulosa cell tumor of the ovary. Granulosa cell tumors of the ovary: prognostic factors and outcome. Treatment of poor prognosis sex cord stromal tumors of the ovary with the combination of bleomycin, etoposide and cisplatin.

J Clinic Oncol. Adult type granulosa cell tumor and FOXL2 mutation. Cancer Res. Articole din ediţiile anterioare Poate salpingectomia bilaterală reduce riscul de cancer ovarian? Panaitescu Cancerul ovarian epitelial reprezintă a cincea cauză de mortalitate prin cancer în rândul femeilor. Nu există nicio metodă eficientă de screening p