AIM:Primary ovarian non-Hodgkin's lymphoma is a very rare disease. Median age at diagnosis is estimated at 42 years, something that leads to fertility preservation issues in many cases. This was a case report study, presenting a rare case of bilateral primary ovarian non-Hodgkin's lymphoma.CASE REPORT:A 38-year old nulliparous woman, underwent exploratory laparotomy because of bilateral ovarian masses. Left salpingooophorectomy, partial omentectomy and excision of an ovarian mass of the right ovary was performed. Great effort in order to preserve healthy ovarian tissue of the right ovary as well as the right fallopian tube was given, due to fertility reasons. Final histology showed bilateral diffuse large B-cell primary ovarian non-Hodgkin's lymphoma. Postoperatively, the patient underwent chemotherapy with the CHOP regimen in combination with rituximab. Five years after initial diagnosis, the patient remains well with normal menstrual cycle, without evidence of recurrence.DISCUSSION:Fertility preservation issues in some cases of rare gynecological malignancies could be managed via minimally invasive oncological approach.

The incidence of young women diagnosed with cancer has been globally increasing. In many cases the surgical approach followed by chemotherapy, radiotherapy or hormonal therapy could lead to infertility or premature ovarian failure. Several options are available in order to preserve fertility and increase the future gestation rate. Among embryo cryopreservation and oocyte cryopreservation, ovarian tissue cryopreservation represents an ideal option, especially for premenopausal women and for those who cannot delay the start of chemotherapy. The purpose of this study was to examine the follicle viability using fluorescence microscope before and after ovarian thawing.

We aimed to determine the second-trimester amniotic fluid (AF) levels of soluble Fas (sFas) and Fas-ligand (FasL) and investigate their association with fetal growth. Therefore, sFas and FasL levels were measured by enzyme immunoassay in the AF of 21 small for gestational age (SGA), 13 large for gestational age (LGA), and 44 appropriate for gestational age (AGA) fetuses of pregnant women who underwent amniocentesis at between 15 and 22 weeks gestation. Our study results showed that sFas and FasL levels were detectable in AF. sFAS median (25th–75th centile) levels were 3.8 (2.8–4.6)ng/ml in SGA, 3.6 (3.1–4.5)ng/ml in AGA, and 4.0 (3.1–4.4)ng/ml in LGA. FasL median (25th–75th centile) levels were 26.0 (20.3–32.7)pg/ml in SGA, 22.7 (18.4–28.5)pg/ml in AGA, and 21.5 (15.8–30.9)pg/ml in LGA. The differences were not statistically significant. Nevertheless, statistically significant differentiation of FasL levels existed when SGA fetuses in the extremes of distribution (≤5th, ≤2.5th centile) were considered. This is the first study presenting sFas and FasL concentrations in early second-trimester amniotic fluid in AGA, SGA, and LGA fetuses. We found indications that severe and very severe SGA fetuses (≤5th and ≤2.5th centile) have high levels of FasL in the amniotic fluid. This finding probably reflects the increased rate of apoptosis that is assumed to exist in cases of extreme growth restriction.

OBJECTIVE:The aim of this study was to examine whether resistin is present in second trimester amniotic fluid from trisomy 21 (also known as Down's syndrome) pregnancies and whether its concentration differs compared with euploid pregnancies.METHODS:The study cohort consisted of 58 women in the mid-trimester of pregnancy who underwent amniocentesis for prenatal diagnosis, 31 of whom carried a single fetus with diagnosed trisomy 21 (study group) and the rest with normal karyotype (control group, n = 27). Groups were matched for maternal and gestational age. Levels of resistin in amniotic fluid were measured by a commercially available enzyme-linked immunosorbent assay (ELISA) kit.RESULTS:Resistin was detected in all amniotic fluid samples. Its median concentration in the second trimester amniotic fluid of trisomy 21 pregnancies (2.1 ng/ml) was statistically significantly lower (p value <0.001) in comparison with that in euploid pregnancies (3.3 ng/ml).CONCLUSIONS:Resistin is a physiologic constituent of second trimester amniotic fluid. Lower levels of amniotic fluid resistin in pregnancies with trisomy 21 may reflect altered metabolic pathways in utero that could possibly be related with phenotypic features of the syndrome.

PURPOSE:The objective of this study was to evaluate the effect oftamoxifen on the endometrium of45 postmenopausal women with breast cancer, as evidenced by hysteroscopic, ultrasound, histological methods, and by immunohistochemical investigation of the expression of Bcl-2 and Ki67.MATERIALS AND METHODS:Forty-five postmenopausal women with breast cancer (ER and/or PgR positive) undergoing tamoxifen therapy for six to 48 months, were selected from the files of the 2nd Department of Obstetrics and Gynecology, University of Athens Aretaieion Hospital, among a total of 120 patients treated from 2004-2009.RESULTS:The ultrasound findings during the follow-up period revealed 18 cases of thickened endometrium, 14 cases of suspected polyps, one case with accumulation of endometrial fluid, and 12 cases of heterogeneous endometrial echo texture. The patients had undergone hysteroscopy because of thickened endometrium (18/45 patients), postmenopausal bleeding (14/45 patients), and polyps (13/45 patients). The endometrial tissue samples were examined in the Pathology Department of Aretaieion Hospital and showed in 23 cases with adenomatous endometrial polyps, 15 cases with endometrial cystic atrophy, two cases with adenomatous hyperplasia, and five cases with mucosal endometrial adhesions. Immunohistochemical investigation of Bcl-2 and KJ67 expression was undertaken on paraffin blocks and showed elevated expression in the cases with endometrial polyps and hyperplasia, in contrast to atrophic endometria.CONCLUSION:Long-term tamoxifen therapy of postmenopausal women with breast cancer is associated with uterine pathology. Ultrasonography alone is useful in asymptomatic patients selecting cases with increased endometrial thickness for further investigation. Hysteroscopy is an accurate method for diagnosing endometrial disease because it provides a direct view of the uterine cavity, reveals focal lesions, and enables targeted biopsies to be performed at the same time. Pathological findings show elevated expression of Ki67 and Bcl-2 in hyperplastic endometria and adenomatous polyps, consistent with an elevated glandular cell proliferation due to tamoxifen effect.

N. Vrachnis1, F.M. Malamas2, S. Sifakis3, A. Parashaki4, Z. Iliodromiti1, D. Botsis1 and G. Creatsas1 12nd Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieio Hospital, Athens, 21st Department of Obstetrics and Gynecology, University of Athens Medical School, Alexandra Hospital, Athens, 3Department of Obstetrics and Gynaecology, University Hospital of Heraklion, Crete, 4Health Center of Thira, Thira, Greece

The aim of this study was to describe a new technique for laparoscopic removal of large ovarian cystic masses. The authors performed a retrospective study during the period January 2008 to December 2009 in the Second Department of Obstetrics and Gynecology of Aretaieion University Hospital; 19 women with large ovarian cysts were included in the study. During the study period, 53 women underwent laparoscopic excision of ovarian cysts. Among them, 19 had very large complex ovarian cysts with a mean diameter of 8.4 cm. The mean age of the patients was 32.1 years. Ultrasound examination revealed findings suggestive of benign disease in all patients. In 8 out of 19 patients CA-125 levels were elevated, ranging from 40.5 to 194.7 IU/mL. A 5-mm suprapubic trocar was directly inserted into the cyst and fluid contents aspirated, so the decompressed cyst could fit in a 5-cm laparoscopic bag. The cyst wall was carefully detached from the healthy ovarian tissue and placed in the bag without any spillage. The remaining cyst wall was removed from the peritoneal cavity with the laparoscopic bag. The mean operative time was 45 minutes. No operative or postoperative complications were noted. There was no conversion to laparotomy. Mean hospital stay was 1 day. Pathology revealed 7 endometriomas, 3 mucinous cystadenomas, 3 serous cystadenomas, 3 serous cysts, and 3 teratomas. Direct trocar insertion within the ovarian cyst followed by aspiration of the fluid contents is a safe and feasible method for the laparoscopic management of large ovarian cysts.

PURPOSE OF INVESTIGATION:To evaluate the diagnostic accuracy of three-dimensional ultrasound (3D-US) and three-dimensional power-Doppler (3DPD-US) as adjuncts to conventional B-mode-US in evaluation of complex benign ovarian lesions.METHODS:Transvaginal B-mode-US, 3D-US and 3DPD-US were performed in 29 patients with unilateral ovarian lesion. Patients were classified as low or high risk for malignancy according to a standardized scoring system composed of ten morphological and vascular parameters. Preoperative scores were matched to the histological results and the diagnostic performance of the scoring system was calculated.RESULTS:Seven out of the 16 cases of endometriomas (44%) were graded as low risk masses according to B-mode-US, while the addition of 3D-US and 3DPD-US increased the accuracy to 56% and 94%, respectively. All dermoid cysts were classified as high risk cases by B-mode-US, but 3D-US and 3DPD-US correctly classified 14% and 57% of cases, respectively. The use of B-mode-US, 3D-US and 3DPD-US correctly classified all four cystadenomas. Only the use of 3DPD-US correctly classified one out of two hemorrhagic corpus luteum cases, whereas the other imaging modalities characterized these lesions as high risk. The overall diagnostic accuracy increased from 38%, 48%, ana 83% with the application of B-mode-US alone, or combined with 3D-US and 3DPD-US, respectively.CONCLUSION:Conventional ultrasound supplemented with 3D-US and 3DPD-US and the evaluation of findings according to a specific scoring system can facilitate the preoperative classification of complex benign ovarian lesions.

We present three consecutive cases of skeletal dysplasias of a non-consanguineous couple with five pregnancies. The diagnosis of short-rib polydactyly syndrome (SRPS) was feasible by ultrasound during the 1st trimester of pregnancy. SRPS represents a heterogeneous group of lethal skeletal dysplasias. It is characterised by short limb dwarfism complicated by thoracic hypoplasia, polydactyly and different anomalies of major organs such as congenital heart defects and renal dysplasia. Four major types of the SRPS have been described: type I (Saldino–Noonan); type II (Majewski); type III (Verma–Naumoff) and type IV (Beemar–Langer). However, there is phenotypic overlapping between four types and with those of non-lethal skeletal dysplasias (i.e. Ellis–van Creveld syndrome and Jeune syndrome). Our cases show the importance of the nuchal translucency (NT) scan that offers the opportunity to examine fetal anatomy in the 1st trimester and diagnose rare skeletal abnormalities early in pregnancy.

N. Vrachnis1, F.M. Malamas2, S. Sifakis3, A. Parashaki4, Z. Iliodromiti1, D. Botsis1 and G. Creatsas1 12nd Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieio Hospital, Athens, 21st Department of Obstetrics and Gynecology, University of Athens Medical School, Alexandra Hospital, Athens, 3Department of Obstetrics and Gynaecology, University Hospital of Heraklion, Crete, 4Health Center of Thira, Thira, Greece

Aim. Congenital cystic adenomatoid lung malformation is a rare unilateral dysplasia of the lung. Three pathologic types are described in the literature: type I with cysts >2 cm, type II with cysts <1 cm, and type III with microcysts. The aim of this paper is to present a case of a fetus with congenital cystic adenomatoid lung malformation and discuss the necessity for pregnancy termination according to its prognosis and future mortality. Case. A 36-year-old pregnant woman (para: 1, gravida: 1) presented in our department for anatomy ultrasound screening at 20 + 1 weeks of gestation. The ultrasound detected a cystic adenomatoid right lung malformation measuring 1.45 × 1.67 cm which caused mediastinal shift of the heart and the lung to the left side. Other findings were cysts of the choroid plexus and echogenic intracardiac foci. The parents after genetic counseling decided pregnancy termination. The pregnant received cabergoline for ablactation. Conclusion. Congenital cystic adenomatoid lung malformation has different prognosis according to the type (69% in type I, 0% in types II and III). Fetal hydrops, cardiac and skeletal anomalies, Potter's syndrome, and gastrointestinal atresia are common cofindings. Genetic counseling is necessary, and pregnancy termination is proposed to the cases with poor prognosis.

Objective . We investigated whether the concentration of the glycoprotein fetuin A is altered in the second trimester amniotic fluid of trisomy 21 pregnancies compared with euploid pregnancies. Methods . 25 pregnancies with an extra chromosome 21 were matched for maternal and gestational age with 25 pregnancies with normal karyotype. Levels of fetuin A in amniotic fluid were measured by a commercially available enzyme-linked immunosorbent assay (ELISA) kit. Results . The median concentration of fetuin A in amniotic fluid of trisomy 21 pregnancies (5.3 ng/ml) was statistically significantly lower (P value=0.008) compared with that in euploid pregnancies (6.8 ng/mL). Conclusion . Lower levels of fetuin A in trisomy 21 may indicate an association with altered metabolic pathways in this early stage that could potentially be associated with features of the syndrome, such as growth restriction or impaired osteogenesis.

PURPOSE:To assess the diagnostic value of transvaginal sonography (TVS) measurement of the endometrium compared to hysteroscopic findings and histopathologic reports in order to facilitate clinical management in asymptomatic postmenopausal women with thickened endometrium.METHODS:During the period between January 2000 and December 2008, a retrospective analysis was performed including cases of women who were preoperatively diagnosed with a sonographically thickened endometrium, while asymptomatic, and therefore underwent hysteroscopic and fractionated dilatation and curettage (D & C) under general anesthesia at the Second Department of Obstetrics and Gynecology at Aretaieion Hospital in Athens, Greece. In the present study we compare US, hysteroscopic and pathologic findings.RESULTS:The mean age of the patients ranged between 54-74 years (mean age 65.2 +/- 6.8 years). In 108 cases, sonographically measured endometrial thickness ranged between 5 and 10 mm. In 59 cases, endometrial thickness ranged between 11 and 15 mm, whereas in 22 cases, between 16 and 20 mm and finally, in 13 cases endometrial thickness was more than 20 mm. Hysteroscopic examination revealed endometrial polyps in 161 cases, focal hyperplastic lesions in 28 cases, complete hyperplastic lesions in five cases while atrophy was found in five and cancer in three cases, respectively. Pathological results of the samples taken after hysteroscopy are as follows: in 169 cases (83.67%) in women with asymptomatic abnormal endometrial thickness, an endometrial polyp was present. Endometrial thickness in these cases patients was 10.9 +/- 7.5 mm. In patients with focal hyperplasia (22 cases), endometrial thickness was 7.2 +/- 0.5 mm but in patients with complete hyperplasia (5 cases) endometrial thickness was higher (12.3 +/- 5.1 mm). Finally, in three cases with endometrial carcinoma endometrial thickness was 15.5 +/- 7.8 mm. Six cases out of 28 described in our study were diagnosed as focal hyperplasia and two out of five cases as complete hyperplasia, whereas histological reports classified these cases as endometrial polyps. The other histological diagnoses confirmed hysteroscopic findings and thus provided the same results.CONCLUSIONS:We recommend hysteroscopy to follow gynecological TVS when a thickened endometrium is found in asyptomatic postmenopausal women for better diagnostic and, in a later stage, therapeutic efficacy.

The aim of this prospective study is to assess the detection rate of cardiac defects during the routine nuchal translucency (NT) scan by examining the four chambers of the fetal heart. All pregnancies that were examined prospectively by ultrasound assessment during the first trimester (11th–14th week), the second trimester (19th–24th week) and third trimester were included in the study. During the period November 2006—March 2010, 3174 fetuses were examined. Fetal heart was assessed during the nuchal scan by examining the four chambers view while detailed echocardiography was performed during the anomaly and growth scans. Diagnosis of congenital heart defects (CHD) was further confirmed by a fetal cardiologist while postnatal confirmation was available in all cases. The four chambers view was obtained in 99.52% of the cases. During the study period, CHD were diagnosed in 22 fetuses (0.693%). Nine cases were detected during the nuchal scan (40.9%), 11 cases (50%) during the anomaly scan, 1 CHD (4.54%) during the growth scan and 1 postparum (4.54%). Mean NT was higher in those CHD that were diagnosed in the first trimester (mean NT 5.3, median 1.5) compared to those diagnosed later in pregnancy (mean NT 1.6, median 1.5). 18.2% of all CHD were from in vitro fertilization (IVF) pregnancies. Assessment of the four chambers of fetal heart during the nuchal scan was feasible and allowed the detection of 40.9% of CHD. Detailed examination of fetal cardiac anatomy during the routine NT scan may further improve the detection rate providing pregnancy management information early in the first trimester.

To evaluate changes of urethral and bladder neck position and mobility in women suffering from stress urinary incontinence after a tensionfree vaginal tape—obturator (TVT-O) operation by ultrasonography. This cross sectional study included 46 women with urodynamically confirmed stress urinary incontinence scheduled for suburethral sling operation divided into two groups. The control group consisted of 22 patients underwent transperineal ultrasound examination pre-operatively and the study group of 24 underwent a TVT-O operation. Two months after the operation their lower urinary tract was examined by transperineal ultrasound. Ultrasound assessment of the lower urinary tract was performed in accordance with the guidelines of the German urogynecology working group. Changes of urethral and bladder neck position and mobility were evaluated at rest and maximal Valsalva in all women in order to assess the impact of TVT-O operation. TVT-O operation decreased the mobility of all urethral parts during valsalva. Medians of absolute differences between measurements at rest and at maximal valsalva were higher at the control compared to the study group at all reference points indicating a tendency of higher urethral stability in those women that underwent TVT-O operation. Especially at the level of the urethrovesical junction, the median of the absolute differences between measurements at rest and at maximal valsalva decreased significantly from 4.75 at the control group to 1.4 at the study group 2 months after TVT-O procedure (P < 0.05). Furthermore, at the level of middle urethra the median of the absolute differences between measurements at rest and at maximal valsalva decreased significantly from 3.8 at the control group to 0.8 after TVT-O procedure (P < 0.05). TVT-O procedure can affect urethral and bladder neck stability by a significant reduction of mobility at the level of middle urethra and at urethrovesical junction both at rest and during Valsalva.

AIM:Human beta defensins 2 (HBD2) and 3 (HBD3) are peptides expressed in the amnion and chorion. This is a matched case control study conducted in our Department to determine whether second trimester amniotic fluid HBD2 and HBD3 concentrations measured at the time of genetic amniocentesis could be potential markers of preterm labor prediction.METHODS:Amniotic fluid HBD2 and HBD3 were determined by an enzyme-linked immunosorbent assay (ELISA) Women with preterm labor were defined as cases (N=41) while for each case a woman matched for age delivering at term served as control (N=41). Subgroup analysis was conducted to examine possible associations of HBD2 and HBD3 in cases of premature rupture of membranes. Nineteen women with preterm labor and premature rupture of membranes were defined as cases while for every case a woman matched for maternal age delivering at term served as control (N1=19). Results were presented as odds ratios (OR) and 95% confidence intervals. Statistical analysis used STATA 8.2 and SPSS 11.5 edition. A P-value of <0.05 was considered statistically significant.RESULTS:Amniotic fluid concentrations of HBD2 at the time of genetic amniocentesis were positively associated with preterm premature rupture of membranes (P=0.028), but not with preterm labour. No association of HBD3 and preterm birth was documented.CONCLUSION:Second trimester amniotic fluid HBD2 might be a predictor of premature rupture of membranes.

SummaryObjective Autoimmune thyroiditis and overt or subclinical hypothyroidism have been associated with increased prevalence of cardiovascular disease (CVD).Design Cross‐sectional investigation of the association between gene polymorphisms related to CVD with thyroid function and autoimmunity.Patients In total 84 healthy postmenopausal women aged 49–69 years.Measurements FT3, FT4, anti‐TPO and anti‐TG were assessed in the sera of participants. The following polymorphisms were assessed from peripheral lymphocyte DNA: Apolipoprotein E E2/E3/E4, paraoxonase 1 A/B, Glycoprotein IIIa leu33pro, MTHFR ala222val, ApoBarg3500gln, plasminogen activator inhibitor 1 4G/5G, cholesterol 7‐α hydroxylase A204C and cholesterol ester transfer protein B1/B2.Results A statistically significant correlation was found between Apolipoprotein E and paraoxonase1 polymorphisms and serum thyroid hormones: carriers of the E2 or E4 allele of the ApoE gene had lower levels of FT4 (P = 0·0005) than women with the E3/E3 genotype. Carriers of the B allele of paraoxonase 1 gene had lower levels of FT3 compared to women with the wild‐type genotype (P = 0·047). A statistically significant positive association (P = 0·049) was also observed between anti‐TG antibodies and the presence of the E2 allele of the Apolipoprotein E gene.Conclusions Polymorphisms of apolipoprotein E and paraoxonase 1 are associated with different levels of thyroid hormone and anti‐Tg antibody levels in the study population in this pilot study. The mechanism underlying this association remains to be elucidated.

Congenital cystic adenomatoid malformations of the fetal lung (CCAM) are rare embryonic developmental abnormalities. They are considered as benign hamartomatous or dysplastic lung tumors characterized by overgrowth of the terminal respiratory bronchioles at the expense of the saccular spaces. A minority of cases may not be identified by prenatal imaging techniques and the pulmonary lesions are recognized postnatally. Two cases of congenital cystic adenomatoid malformation of the fetal lung diagnosed in our institution during the last four years are reported. The ultrasonographic and pathologic findings of these cases are discussed.