Biomedical subjects
Publications and source records attributed to Z S Tuncer.
A 24-year-old primigravid woman with cogenital hepatic fibrosis associated with cavernous transformation of the portal vein is described. Although the neonate could not survive because of the ileal atresia, the pregnancy and delivery did not pose a significant threat to the mother.
A retrospective analysis of 31 patients subjected to radical surgery and lyphadenectomy for microinvasive cervical cancer was carried out. The mean age of the patients at diagnosis was 51.4 years. Twenty-nine of the patients had depth of invasion of 3 mm or less whereas 5 of them had lymphovascular space invasion. Thus, 24 patients had microinvasive cervical cancer according to the SGO (Society of Gynecologic Oncology) criteria. While nine patients had minimal stromal invasion (< 1 mm) at diagnosis, the remaining 22 patients fulfilled the criteria of FIGO IA2 disease. Most of the patients had grade I disease. With worsening of differentiation lymphovascular space involvement increases from approximately 11% (2/18) to 50% (1/2). None of the patients had lymph node involvement. All patients are living with no evidence of disease with a mean survival of 39 months. Current FIGO criteria for microinvasive carcinoma permits us to define a subset of patients that can safely be subjected to a more conservative approach.
To determine the effectiveness of medical therapy in vulvar dystrophy, a retrospective, single-institute clinicopathologic study of 285 consecutive cases was carried out. Of the patients, 152 (53.3%) had squamous hyperplasia (SH), 72 (25.3%) had lichen sclerosus (LS), and 61 (21.4%) had lichen sclerosus with areas of squamous hyperplasia (LS + SH). Symptomatic response was 84.8% at 3 months and 92.7% at 6 months in patients with SH. These figures were 70.8% and 87.5% for patients with LS and 68.8% and 80.3% for patients with SH + LS, respectively. Histopathological response was 63.6% at 3 months and 74.8% at 6 months for patients with SH. These figures were approximately 29% and 42% for LS, and 21% and 34% for patients with SH + LS, respectively. Corticosteroids for squamous hyperplasia and testosterone for lichen sclerosus achieved a high symptomatic response. However, histologic remission rates were poorer.
The treatment modalities of 88 consecutive patients with uterine sarcomas were reviewed retrospectively in the hope of offering a more rational therapy especially in early stage disease. Of the patients, 47 had Leiomyosarcoma (LMS) (53.4%), 28 had Malignant Mixed Mesodermal Tumor (MMMT) (31.8%) and 8 had Endometrial Stromal Sarcoma (ESS) (9.0%). The patients with uterine sarcoma constituted 7.8% of all patients with uterine malignancies during the study period (88/1124). The mean age of this series at diagnosis was 49.2 years. This figure was 45.1, 53.2 and 35.3 for LMS, MMMT and ESS, respectively. The surgical procedure employed was total abdominal hysterectomy and bilateral salpingoophorectomy (TAH + BSO) in 53 (58.9%) patients and 35 patients underwent TAH + BSO and pelvic and paraaortic lymphadenectomy. The overall incidence of lymph node metastases was 28.5% (4/14) for MMMT and 5.8% (1/17) for LMS cases, respectively. The overall 3-year survival rate of this series was 29.5% (23/88). This figure was found to be 59.4% (22/37) for stage I disease and 27.2 (3/11) for stage II disease; The stage I patients with and without adjuvant therapy had similar survival rates. This study confirms that due to the existence of a substantial risk of lymph node metastasis, a complete surgical staging is necessary in the management of uterine sarcomas particularly of MMMT type. Another deserving finding is the failure to detect any therapeutic effect of adjuvant therapy in stage I patients.
A 24-year-old primigravid woman with adult type Gaucher's disease was admitted at 28 weeks of pregnancy. She was asthenic and the abdomen was markedly protuberant due to hepatosplenomegaly. A conservative approach with close monitorization of both mother and baby was planned. On the 39th week of pregnancy a healthy female baby of 3000 g was delivered via cesarean section. Apart from mild hematological complications, the pregnancy, the delivery and the puerperium were uneventful.
A case of ovarian hyperstimulation syndrome (OHSS) associated with spontaneous pregnancy is reported with the hope of facilitating earlier recognition of this condition. Although OHSS is usually an iatrogenic complication, it can also occur spontaneously without any evidence of endocrinological disorder. Surgery was performed and induced a very rapid resolution of ovarian hyperstimulation.
BACKGROUND: To review the experience of seven cases of gestational trophoblastic neoplasia with central nervous system involvement. METHODS: Seven patients among 50 cases of malignant gestational trophoblastic neoplasia were analyzed retrospectively in a single institution. RESULTS: The mean age of the patients at diagnosis was 28.7 years (range: 20-34). While five of the patients presented initially with symptoms related to cranial involvement, the remaining two developed cerebral metastases during the therapy. In two patients, the presentation was so similar to a primary cranial pathology that craniotomy and biopsy revealed the trophoblastic involvement. The sites of involvement were the parietal lobe in three, temporal lobe in two and frontal lobe in two patients. Besides central nervous system involvement, four had additional lung and one had pelvic metastases. In terms of therapy, while five patients received methotrexate+actinomycin-D+cyclophosphamide regimen for 3 to 5 courses, only two could be administered additional intrathecal methotrexate. Since one patient exhibited a fulminant clinical course, she could not be delivered a chemotherapy regimen and was lost in two months of initial diagnosis. The other patient was administered modified Bagshawe protocol (5 courses) which was switched to etoposide+methotrexate+actinomycin-D+vincristine+cyclophosphamide (6 courses) due to development of resistance. She was still alive and free of disease after 24 months of initial diagnosis. Six of the patients were also delivered whole-brain irradiation simultaneously with chemotherapy. CONCLUSIONS: The prognosis of brain metastases still seems to be poor despite combination chemotherapy and radiotherapy. Measures should be focused on early diagnosis and prophylaxis.
Three cases of serous surface papillary carcinoma of the abdominopelvic peritoneum are presented. All of the patients were subjected to a relatively homogeneous management consisting of primary surgery and cisplatin based chemotherapy regimen. The second look procedures of two patients were found to be negative. Although these tumors are known to have a poor prognosis, aggressive surgery and cisplatin based chemotherapy seem to have promising results.
Since malignant transformation in a dermoid cyst is extremely rare, the clinicopathological characteristics of patients with squamous carcinoma arising in dermoid cyst are evaluated in the hope of offering a more rational therapy. Our first patient was lost to follow-up after surgery. In the second patient, with a gross stage III disease, after extensive surgery and multiagent chemotherapy we were able to achieve a remission period of 42 months. In the third patient with pelvic lymph node metastases, adjuvant radiation and chemotherapy was administered following surgical staging. She was free of disease 6 months after surgery. Malignant transformation in a dermoid cyst is a rare complication observed especially in older age groups. Thus, a frozen section in these decades may improve detection of this complication allowing a more accurate staging. Although poor prognosis is reported, an aggressive approach with cisplatinum based chemotherapy and radiation and even with secondary cytoreduction, long-term remission may be achieved.
Ten patients with Sertoli-Leydig cell tumors of the ovary treated consecutively were analyzed retrospectively for clinicopathological characteristics, treatment modalities and survival. All patients were subjected to a surgical procedure including unilateral salpingoophorectomy (USO) in 5, total abdominal hysterectomy, bilateral salpingoophorectomy (TAH+BSO) in 2, TAH+BSO and omentectomy and pelvic and paraaortic lymphadenectomy and appendicectomy in 3 patients. Following surgery, 5 patients were subjected to adjuvant VAC (vincristine+actinomycine-D+cyclophosphamide) chemotherapy. Sertoli-Leydig cell tumors constitued 0.6% of all ovarian neoplasms in our institution (10/1621). The mean age at diagnosis was 28.2 years. Of the patients, 8 had stage IA, one had IB and one had stage III disease at surgery. Bilaterality was observed in two patients (20.0%). Four patients had poorly-differentiated tumors, of whom 1 had a retiform pattern and 1 had a heterologue element, with marked mitosis whereas the others had well--or moderately--differentiated tumors. Only one patient presented with recurrence during pregnancy and died 16 months after initial surgery. Since most of the patients present with stage IA disease, a favorable outcome can be achieved in most of them and conservative surgery seems to be the treatment of choice in younger patients. However, late recurrences even in early stages, especially in patients with poorly-differentiated tumors, can be detected, resulting in a fatal outcome despite any form of aggressive therapy.
OBJECTIVE: To determine the most significant factors for persistent disease in women with hydatidiform mole. STUDY DESIGN: Eighty-two patients who were managed consecutively without prophylactic chemotherapy between 1973 and 1993 were analyzed retrospectively for clinical and pathologic features, including age of the patient, size of the uterus, human chorionic gonadotropin (hCG) level, presence of theca lutein cysts, evidence of preeclampsia or hyperthyroidism, history of hydatidiform moles, trophoblastic hyperplasia, nuclear atypia, necrosis and hemorrhage, trophoblastic maturation, presence of fibrinoid layer and ratio of cytotrophoblast to syncytial trophoblast. RESULTS: Thirty-one patients developed persistent trophoblastic neoplasia (38%). Of the parameters evaluated, elevated hCG level, advanced age, history of hydatidiform mole, presence of hyperplasia, marked nuclear atypia and necrosis, and hemorrhage were significant risk factors for persistent neoplasia after univariate analysis. Among the factors analyzed, trophoblastic hyperplasia (relative ration [RR] = 3.56), age (RR = 2.87) and history of mole (RR = 2.57) were identified as the most powerful indicators of persistent disease after multivariate analysis. CONCLUSION: Evaluation of the clinical and pathologic features, such as age, history of mole and presence of trophoblastic proliferation may aid in defining a subset of patients at high risk for persistent disease, who require closer follow-up and administration of prophylactic chemotherapy.
One hundred sixty-eight patients treated at Hacettepe Hospital between 1969-1993 with metastatic ovarian tumors constituted 21.5% of all malignant ovarian neoplasms. Primary tumors were endometrial (51), breast (27), colorectal (18), and stomach cancer (17), lymphoma (14), sarcoma of the uterus (13), undetermined (11), tumors of the appendix (6) and ileum (4), carcinoma of the cervix (4), and gestational trophoblastic neoplasia (3). Overall 5-year and median survivals were 20.0% and 26.8% months, respectively. While worse prognoses were seen in gastric cancer and undetermined tumors followed by colorectal cancer, best survival figures were observed in endometrial cancer patients. A trend toward a better survival was seen with the advancement of the operation from bilateral salpingooophorectomy, and/or biopsy to total abdominal hysterectomy, bilateral salpingooophorectomy, total omentectomy, pelvic and paraaortic lymphadenectomy with debulking. Multivariate analysis identified the primary site, grade, laterality of involvement, type of surgery and adjuvant therapy status as significant prognostic parameters. Maximal surgical effort followed by adjuvant therapy might at least have some short term survival benefit in certain types metastatic to the ovaries.
OBJECTIVES: To evaluate genital fistulas with the aim of improving strategies to prevent them. METHOD: An institutional, retrospective, clinical analysis. One hundred eighty-two patients with genital fistulas managed consecutively between 1970 and 1993 were analyzed. RESULTS: About 60% of all fistulas were attributable to obstetric traumas whereas gynecologic surgery constituted only 24.7% of cases. The contribution of gynecologic surgery increased from 11.1% in 1970-75 to 60.6% in 1988-93. Approximately half of the patients had vesico-vaginal fistulas. Of the 45 patients with fistulas occurring following gynecologic surgery, 19 had undergone simple hysterectomy and eight had undergone radical hysterectomy. All cesarean sections had been performed after failed labor. Hysterectomy was performed due to myoma in nine patients, endometrial hyperplasia in two patients and pelvic relaxation in eight patients. As regards management of fistulas, the transvaginal approach was chosen in the vast majority of patients. The overall success rate after the primary repair of fistulas was 91.5% (162/177). Fifteen patients with failure of the primary repair were subjected to repeat repairs. The second repair was successful in 11 patients but the remaining four needed further repairs. The maximum was seven repairs to a recto-vaginal fistula before a satisfactory result could be achieved, which had initially occurred after a cesarean section. CONCLUSION: Although the results of reparative surgery are promising, it would be more useful to encourage national measures to prevent in particular obstetric trauma.
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Although rheumatic diseases are reported to be almost eradicated in the developed countries, they still continue to contribute significantly to maternal mortality in the developing world. Surgical therapies need to be considered for those patients who do not respond satisfactorily to medication. However, valve replacement or valvulotomy during pregnancy carries significant risks for both the mother and the fetus. Two patients with severe mitral stenosis refractory to medical therapy are presented. Both patients were subjected to percutaneous balloon valvuloplasty during pregnancy without any complications. They were able to discontinue medication and deliver vaginally at term. Balloon valvuloplasty appears to be a safe alternative to conventional surgical approaches in pregnancy.
A retrospective analysis of 36 patients with metastatic nodes out of 209 consecutively managed patients with a clinically stage I endometrial cancer was carried out. Of the 1023 lymph nodes removed, 154 nodes were found to be metastatic. The mean number of the involved nodes was 4.27 (range: 1-29). Of the 154 positive nodes, 3 had nodal diameters < or = 3 mm (1.9%), 84 had diameters of 4-10 mm (54.6%), 60 had diameters of 11-20 mm (39.0%) and 7 had diameters more than 20 mm (4.5%). With increasing lymph node size, the frequency of tumoral involvement varies from 1.0% in nodes < or = 3 mm to 63.6% in nodes bigger than 20 mm. In terms of patients, nine of them were found to have a single metastatic node ranging from 6 mm to 10 mm in diameter. In the remaining 27 patients with multiple metastatic nodes, the biggest nodes encountered were 6-10 mm in 4 (14.8%), 11-20 mm in 17 (62.9%) and more than 20 mm in 6 (22.2%) patients. Since mere sampling of the lymphatic tissue directed particularly to the enlarged nodes may not show the true incidence of positive nodes, a complete lymphadenectomy is advocated in order to obviate an understaging problem.
BACKGROUND: To determine the most important prognostic factors in patients with malignant germ cell tumors of the ovary. METHODS: Age, histologic type, tumor size, stage, treatment mode, type of surgery of 67 patients with malignant germ cell tumors managed consecutively were evaluated retrospectively using multivariate analysis. RESULTS: The overall survival rate was 60.6%. This figure was 78.5% for dysgerminoma, 53.3% for immature teratoma, 12.0% for endodermal sinus tumor, 33.3% for mixed germ cell tumor and 100.0% for others. The patients with endodermal sinus tumor had significantly poorer survival than other groups. Among the factors analyzed for survival histologic type was found to be the most significant predictor for survival. CONCLUSIONS: Finding of histologic type as the strongest independent risk factor may be evaluated in correlation with the literature that these tumors have historically been investigated as dysgerminomatous and nondysgerminomatous tumors. Furthermore, endodermal sinus tumors had long been known for poor survival. Based on this data, despite advent of staging and effective chemotherapy, prognosis still is basically related to histologic type and histology of tumor should be taken into account while comparing results.
OBJECTIVE: To highlight recent trends in maternal mortality in Hacettepe University Hospital. METHOD: A retrospective clinical analysis of 117 maternal deaths between 1968 and 1992. RESULTS: The overall maternal mortality ratio was 180/100,000 (108/59,993). In terms of 5-year periods, the maternal mortality ratio declined from 417.7 in 1968-72 to 73.7 in 1988-92. Infection was the most common cause of death (59.8%), followed by cardiac disease (8.5%) and hemorrhage (8.5%). Infection related deaths were either due to septic abortion (75.7%) or puerperal sepsis (24.3%). While 73.9% of all deaths were due to infection in 1968-72, this figure contributed only 9.1% of the deaths in 1988-92. When infection, hemorrhage, cardiac disease ad toxemia are investigated together, percentages of their contribution varies from 95.7% in 1968-72 to 54.5% in 1988-92 period. CONCLUSIONS: Maternal mortality ratios are decreasing significantly in our institution. An another promising finding is the further reduction in direct causes especially in recent years. However, an improvement in the care of pregnant women is necessary to continue this declining trend.