Tehran University Medical Journal

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Background: The aim of this investigation is to evaluate the histologic results of biopsy in women with atypical squamous cells of undetermined significance (ASCUS) cytologic diagnosis.

Materials and Methods: We reviewed a series of cases with ASCUS pap smears from March 1999 to Feb 2002 in Imam Khomeini Hospital (n= 104), Who had cervical biopsy indirected colposcopy (103) and in Onec endocervical biopsy obtained without colposcopy. In 60 patients before colposcopy and biopsy repeat pap smear was tabled.

Results: Biopsy revealed 28.8% SIL (14 LSIL and 16 HSIL), 1 invasive carcinoma and 1 endometrial carcinoma. Pap smear repeated for 60 women before colposcopy examination, which 7 (11.7%) of them were normal. ASCUS persisted in 45 cases (75%) and 8 cases (13.3%) turned out to be SIL (6 LSIL, 2 HSIL) of 7 normal repeat smear, 2 marked as LSIL by biopsy. In colposcopic examination 22 of 103 (21.4%) had normal view which one of them was LSIL histologically.

Conclusion: Based on these findings, it seems immediate colposcopy and directed biopsy are appropriate procedures for management of ASCUS and to detect underlying SIL.

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Background: Cerebral metastases from choriocarcinoma are poor prognostic indicator of outcome in both the World Health Organization and FIGO classification systems. Although gestational trophoblastic neoplasia has become the most curable gynecological malignancy, failure rate among “high-risk” patients is still high despite the use of aggressive multidrug regimens.
case: A 27 year old woman (G4P2Ab1) presented with hemiplegia due to brain metastases of choriocarcinoma one year after spontaneous abortion. She underwent craniotomy and was treated with nine courses of multiple agent etoposide, methotrexate, actinomycin-etoposide and cisplatinum (EMA-EP) regimen combined with whole brain irradiation. She delivered a term healthy child two years after termination of treatment. Conclusion: Multiagent EMA-EP chemotherapy and whole brain irradiation with craniotomy in selected patients preserves fertility and may improve a patient overall prognosis. Methods: In a descriptive study from February to April 2005, two hundred sixty six consecutive pregnant women referring to a university hospital were asked to answer a questionnaire containing questions their sexual status and some demographic data. In 122 cases the answers of the spouses was collected also. The answers were compared in divided groups according to age range, duration of marriage, parity and educational status.
Results: Fifty five percent of men and fifty eight percent of women had a negative attitude about sexual relations during pregnancy, and 60% of men and 75% of women presented incorrect knowledge about sexuality during pregnancy. Main reasons for decreased sexual relations in pregnancy were mentioned to be dysparaunia, and the fear of trauma to the baby, abortion, membrane rapture, preterm labor and infection.
Conclusion: As couples’ knowledge and attitudes about sexuality affect their general sexual behavior during pregnancy it is crucial to provide proper consultation regarding sexual relations in prenatal care services.

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Background: The currently accepted treatment of scoliosis are bracing and surgery. Two-stage anterior and posterior spinal fusion is used to correct scoliosis. It seems that the application of a longitudinal force to the axis of the spinal column as a means of stabilizing by halo traction, may increase the correction of the curve. The aim of this study was to evaluate the effect of halo traction used between the two stages of corrective surgery, anterior and posterior spinal fusion, on the correction of scoliosis curvature.
Methods: In this randomized clinical trial twelve scoliotic patients, aged from 12-19 years old, were treated by two-stage anterior spinal release and fusion (ASF) and posterior spinal fusion (PSF). The patients were divided in two groups: 6 scoliotic patients without any traction between ASF and PSF surgeries (group A), and 6 scoliotic patients were undergone halo traction for one week between ASF and PSF surgeries (group B). Major curve angle was measured before surgery, one week after ASF and one year after PSF surgeries. Data were collected and analyzed using SPSS v.13.5.
Results: The mean baseline curve angles were 90° (SD=18.70) and 94.17°(SD=28.18) in groups A and B, respectively. Whereas, the mean final curve angles (one year after PSF) were 51.17°(SD=29.59) and 39.17°(23.11) in groups A and B, respectively. Final angle improvement was 46.58% (SD=20.31) in patients without traction and 61.32% (SD=14.02) in patients with halo traction. The major curve angles showed significantly better correction in patients with traction one week after ASF [38.67°(SD=7.86) vs. 25°(SD=6.28), P=0.012]. This difference persisted at the end of the first year after operation. [55°(SD=8.94) vs. 38.83°(SD=11.65), P=0.022].
Conclusion: Application of halo traction between ASF and PSF surgeries may lead to better improvement of the scoliotic curvature and short time application of halo traction decreases possible complications.

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Background: Access to a safe and efficient chemotherapy regimen for improving the survival and live quality is a goal in ovarian carcinoma. Despite surgery is the base treatment of ovarian cancer, but in most patients chemotherapy is used due to progression of their disease. This study designed to compare two important chemotherapy regimens.
Methods: This historical cohort study compared two chemotherapy regimen cisplatin (75mg/m2)+ cyclophosphamide (750mg/m2), versus taxol (175mg/m2)+ carboplatinium (GFR+25)AUC between 1998-2005 in valiasr hospital. In this study toxicities of two regimes were compared. The survival function in these two groups were analysed with Kaplan-Meire curve.
Results: Gastrointestinal and mucosal toxicity were significantly higher in CP group compared TC group (p=0.02). Also there were no significant relation between decrease of serum CA125 and patient remission length in CP group but in other group with decrease of CA125 in lower than three cycle we had an increase in patient remission period. (P=0.02). Disease free interval in cisplatin group was longer versus taxol group (p<0.05), there was no significant difference in overall survival in two group.
Conclusion: This study revealed that cisplatin plus cyclophosphamide regimen can yet be used as a chemotherapy treatment in ovarian cancer. In this study there was no significant benefit in taxol regimen compared CP. In the adjuvant therapy of epithelial ovarian carcinoma.

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Cervical cancer is the second most common gynecologic cancer. A steady 70% annual decline in mortality from cervical cancers has been observed since the mid 20th century after the introduction of widespread papanicolaou cytological screening. But also cervical cancer continues to be an important world health problem for women. Cervical cancer is one of the best- understood neoplasm given its well known viral cause of persistent infection with high risk human papillomavirus (HPV). To date, two manufacturers have developed HPV vaccines composed of noninfectious, recombinant HPV viral-like particles (VLPs). This article presents current advances and perspectives on HPV vaccines.The vaccine is administered by intramuscular injection, and the recommended schedule is a 3-dose series with the second and third doses administered 2 and 6 months after the first dose. The recommended age for vaccination of females is 11-12 years. Vaccine can be administered as young as age 9 years. Catch-up vaccination is recommended for females aged 13--26 years who have not been previously vaccinated. Vaccination is not a substitute for routine cervical cancer screening, and vaccinated females should have cervical cancer screening as recommended.

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Background: Although endometrial cancer is primarily a disease of the postmenopausal female, 25% of patients are premenopausal, with 3-5% in women 40 years old or younger. The younger group of women with endometrial carcinoma are frequently nulligravid with a history of infertility, and a strong desire to preserve fertility. This may pose a therapeutic dilemma for both patients and treating physician.
Case report: We reported 3 young patients with atypical complex hyperplasia or early stage endometrial cancer that treated with conservative hormonal therapy.
Conclusion: Medical treatment of young patients with endometrial carcinoma and complex atypical hyperplasia who wish to preserve fertility is a reasonable and appealing option. A comprehensive evaluation prior to counseling the patient should include A complete history and physical examination. A formal D&C with review of history with an experienced gyn-onc pathologist. Evaluation of the pelvic and abdomen preferably with contrast-enhanced MRI or transvaginal ultrasound. In patients found to have a clinical stage I grade I tumor and who want to preserve fertility , thorough counseling include risks and benefits, and explanation that the data is partial and incomplete due to the lack of appropriate controlled studies is mandatory. In patients considered for medical treatment, a high dose progestin regimen should be started with endometrial sampling every 3 months until complete regression of the tumor is documented. Although most responses are long standing, there is a small risk of progression during or after cessation of progestin therapy.

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Background: The aim of this study was to evaluate the association between atypical glandular cell (AGC) on Pap smear and significant pathologic finding to tailor management protocols.
Methods: Between 2002 and 2005, Among 26893 Pap smears 122 women with AGC Pap smears (prevalence=0.45%) were referred to our colposcopy clinic. Forty one women underwent colposcopy directed biopsy, endocervical curettage, endometrial sampling and cervical conization to determine the cytologic and histologic correlations of AGC on pap smears.
Results: A total of 122 women with AGC Pap smear were found. Only 41 women accepted to participate in the study and followed the workup procedures. The mean age of the patients was 46.92 ±11.48 years (range, 23-80 years). Of these patients 13 patients (31.7%) were post menopause and 28 patients (68.2%) were in reproductive age. We found 13 (31.7%) significant pathologic findings including 4 (9.7%) high grade squamous intraepithelial lesion (HG-SIL), 3(7.3%) low grade squamous intraepithelial lesion (LG-SIL), 2(4.8%) Endometrial hyperplasia, 1(2.4%) Endometrial adenocarci-noma, 1(2.4%) adenocarcinoma of cervix, 1(2.4%) squamous cell carcinoma of cervix and 1(2.4%) papillary serous tumor of ovary. There was not any significant difference in the prevalence of significant pathologic findings and subtype of squamous or adenomatous lesions between pre and postmenopausal group.
Conclusion: AGC on Pap smear was associated with a clinically significant diagnosis in approximately one third of our cases. The women with a diagnosis of AGC on cervicovaginal smear are needed to be evaluated at least with colposcopy, endocervical and endometrial curettage. Clinicians should be careful about the significance of AGC in pap smears.

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Background: The aim of this study was to compare the outcome of treatment for ovarian cancer patients who have been treated by gynecologist oncologists and patients who have been treated by general gynecologists or general surgeons.

Methods: We enrolled in this cohort retrospective study all patients diagnosed with primary ovarian cancer in Vali-e-Asr Hospital, Tehran, Iran, between April 1999 and January 2005. A total 157 consecutive patients with ovarian cancer were available for analysis. Of these, 60 patients were treated by gynecologist oncologists and 95 by general gynecologists, and two patients were treated by general surgeons.

Results: The number of patients who underwent optimal cytoreductive surgery (residual tumor <1 cm) was higher in the gynecologist oncologist group, than in the general gynecologist group (P<0.001). Repeated surgeries were required for a majority of patients in the general gynecologist group, while only a few patients in the gynecologist oncologist group needed a second operation (P<0.0001). The interval between the initial surgery and the beginning of chemotherapy was significantly longer in the gynecologist oncologist group compared to that of the general oncologist group (P=0.001). Overall survival and disease-free survival was considerably greater in the gynecologist oncologist group. Optimal cytoreductive surgery and stage of disease are prognostic factors in patients with ovarian cancer. We can therefore conclude that patients with ovarian cancer who are treated by gynecologist oncologists have a better outcome.

Conclusions: We suggest that patients requiring cytoreductive surgery for ovarian cancer be referred to a gynecologist oncologist rather than having a less specialized physician care for such cases.

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Background: Congenital scoliosis is a developmental disorder defined as a lateral curvature of the spine. Its progressive trend and complications, such as cosmetic problems, pain and pulmonary symptoms, have put scoliosis as an important skeletal deformity that should be corrected. One of the currently accepted methods of treatment is posterior spinal fusion (PSF) that may be performed with or without instrumentation. However, the use of implants in conjunction with PSF in congenital spine deformity has been debated over the past three decades primarily because of increased risk of neurological deficit and implant displacement. The aim of this study was to compare short-term and long-term outcomes of spinal fusion with and without posterior instrumentation in congenital scoliosis.

Methods: In this historical cohort study, 41 patients with congenital scoliosis were recruited. All patients underwent PSF surgery between 1977 and 1996. They were divided into two groups according to the use of instrumentation: 22 congenital scoliotic patients who were treated by PSF without any instrumentation (group A), and 19 instrumented PSF patients (group B). Instrumentation was mostly performed using the Harrington rod. The major curve angle was measured before surgery, two weeks and one year after PSF surgery and at the end of the follow-up period.

Results: The mean baseline curve angles were 66.3° and 69.1° in groups A and B, respectively. The mean Cobb angles one year after PSF were 43.1° and 38.4° in groups A and B, respectively. The mean follow-up period was 8 years (SD=3) and, at the end of this period, the final Cobb angles were 47.3° and 39.4° in groups A and B, respectively. Therefore, the final angle correction was 28.7% in patients without instrumentation and 43% in patients with instrumentation. The mean loss of correction was 5.5% and 4.3% in groups A and B, respectively. The final curve angles was significantly more corrected for those patients in whom instrumentation was used than those without instrumentation (p<0.05).

Conclusion: The treatment of congenital scoliosis can be very challenging despite the benefits of modern surgeries and instrumentation methods. The results of our study demonstrate that the application of an implant with PSF surgery may lead to increased improvement of the scoliotic curvature in the short-term and long-term periods, as well as a decrease in the loss of correction and the rate of reoperation. In addition, the low incidence of complications in our study indicates the safety of the posterior instrumentation for the treatment of congenital scoliosis.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 !mso]> ject classid="clsid:38481807-CA0E-42D2-BF39-B33AF135CC4D" id=ieooui> Background: Ovarian cancer is the leading cause of death among all gynecologic cancers in developed countries. The standard treatment for advanced ovarian cancer consists of cytoreductive surgery associated with a platinum/paclitaxel-based chemotherapy. Over than 50% of patients with advanced ovarian cancer will develop recurrent disease. For those patients who have recurrence of disease at least six months after initial therapy, the paclitaxel- platinum combination has been shown to be a superior treatment to platinum monotherapy. However, many patients develop clinically relevant neurotoxicity, frequently resulting in treatment discontinuation. The efficacy and safety of an alternative regimen that dose not show significant neurotoxicity were evaluated by comparing gemcitabin- carboplatin with carboplatin in platinum sensitive recurrent ovarian cancer patients in a Gynecologic Cancer InterGroup trial in Canada and European Organization for research and treatment of Cancer Gynecological Cancer Group. But this study was not done in Iran.
Methods: We performed a study with escalating doses of gemcitabin combined with carboplatin in 21 patients. All patients who were treated in Vali-Asr hospital between 2003- 2005 evaluated. Gemcitabin with dose of 800mg/m² was given on days 1, 8 and 15 followed by one week rest period for a 28 day cycle. Combine with carboplatin with AUC 4 given on day 2. All patients with surgically resected, histologically confirmed epithelial ovarian cancer and who had failed first- line platinum chemotherapy were allocated to this study.
Results: Median age was 49 years (range 23-78 years). Median follow-up was six months (range 4-22). Total of 87 cycles of chemotherapy were administered with median number of four (range 2-6 cycles). Thrombocytopenia (grade I) and leucopenia (grade I) were seen in 4.75% and 9.52% of patients.
Conclusion: Gemcitabin and carboplatin Combination was tolerated in patients with recurrence of ovarian cancer.

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Background: Degenerative spondylolisthesis is a common disease of the lumbar spine especially in older ones. The disease represents a challenge to the treating physician. At present, for those patients that deteriorate clinically, there are many proposed algorithms for the surgical treatment. This before and after study was undertaken to assess the surgical results of decompression and instrumented posterolateral fusion in these patients.

Methods: The study population consisted of 23 patients who had undergone no prior surgery for degenerative spondylolisthesis on the lumbar spine. These patients were treated by decompression, bilateral posterolateral fusion, and segmental (pedicle screw) instrumentation with mean follow-up of 29 months (range, 13-73 months). Finally, The clinical results were evaluated for all patients by means of an Oswestry Disability Index (ODI) version 2.1, the Henderson's functional capacity, and persistence of leg symptoms, low back pain or claudication. Mann-Whitney and Chi-Square tests were used to assess the average values and comparison, respectively.

Results: Henderson's functional capacity at the last visit session was excellent in 14 (60.9%), good in 7 (30.4%), fair in 2 (8.7%) cases. ODI decreased from 72.2% (50-88%) preoperatively to 14.4% (0-54%) at the latest follow-up visit. A history of leg pain or claudication was correlated significantly with the amount of decline in ODI score and Henderson's functional capacity (p<0.05).

Conclusion: In spite of limited number of our patients, decompressive surgery plus instrumented posterolateral fusion is a safe, reliable, and satisfactory procedure for treating degenerative lumbar spondylolisthesis. This procedure may be done when conservative treatment was failed and psychological problems can be ruled out.

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Background: The aim of this study was to assess the role of consolidative intraperito-neal chemotherapy with carboplatin in decreasing relapse and increasing survival in advanced epithelial ovarian cancers, as well as evaluation of its toxicity. Methods: In this clinical trial 30 patients with epithelial ovarian cancer in stages II-IV who had complete surgery (optimal debulking surgery) received six standard cycles of intravenous carboplatin and paclitaxel. They were enrolled through non-random se-quential selection. The control patients were similar to case group in stage (II-IV) and pathology (epithelial ovarian cancer). The control group was evaluated retrospectively through hospital files. This clinical trial performed in Gynecology Oncology department in Tehran Valiasr University Hospital, during 2005-2010. They including 18 cases as the intervention group receiving intraperitoneal chemotherapy and 12 patients as the control group with only retrospective follow-up. The cases received 3 cycles of 400 mg/m2 intraperitoneal carboplatin every 21 days following intravenous chemotherapy. Relapse of disease was diagnosed as increasing or even doubling CA125 serum titer during one month, or any CA125 above 100 IU, or an abdominal or pelvic mass in ul-trasound or physical exam. Mean survival of two and five years, progression-free inter-val (PFI), overall survival (OS), relapse, demographic parameters, drug toxicities, path-ologic types of cancers in two groups were coded and compared using SPSS 14. Any P<0.05 was considered as a significant difference. Results: The mean ages of cases and controls were 52.4±8.6 and 55.1±11.5 years. The mean duration of relapse-free survival was 13±8.6 months for the cases and 9.5±4.3 months for the control patients (not statistically different, P>0.05). The mean overall survival for cases and controls were 39±16.5 and 30.8±16.2 months, respectively (no significant difference, P>0.05). The frequency of drug toxicities in the cases was 5.6%, and consisted of mild-to-moderate abdominal pain, nausea and vomiting. Conclusion: It seems that consolidation therapy with intraperitoneal carboplatin may not increase overall survival, reduce relapse rate or decrease mortality, though it does not induce considerable side effects. Since the mean survival in the intervention group was nine months more than controls, this difference may be clinically significant.

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