MRI is an effective tool for detection of ovarian neoplastic lesions. However, there are no highly specific radiological features that differentiate primary from metastatic ovarian masses. Histological diagnosis preoperatively is not always possible as there is a risk of disseminating an otherwise early stage primary ovarian cancer. The preoperative diagnosis of an ovarian lesion is therefore heavily dependent on the radiological features. The radiologist must rely on a combination of knowing the natural history of any known primary cancer, together with the radiological features such as bilaterality, mucinous appearance, pseudomyxoma as well as the clinical progress of the primary tumour in order to evaluate and predict the likelihood of metastatic disease. Even if a non-ovarian primary cancer is known, an ovarian mass cannot always be assumed to be a secondary lesion. Some tumours, such as BRAC-positive breast cancer, are known to have a high rate of concomitant primary ovarian cancer. Conversely, other tumours, such as gastric and appendiceal cancer, are known to have a high rate of ovarian metastatic disease. However, histology remains the only true way to determine an ovarian metastasis from a primary lesion.
Key content Cervical cancer continues to affect many women in the UK with over half under the age of 45 years at the time of diagnosis; with a trend towards starting families later in life this raises fertility concerns. While the standard treatment for stage IA2 or IB1 cervical cancer is a radical hysterectomy, radical trachelectomy has been shown to have equivalent 5‐year survival and is a surgical option if there is a wish to preserve fertility. Although trachelectomies are performed by gynaecological oncologists, the management of any subsequent pregnancies falls under the remit of obstetricians who therefore require a sound knowledge of the procedure and potential obstetric sequelae. Pregnancies following trachelectomy are high risk because of the increased rate of mid‐trimester miscarriage and preterm delivery, often as a consequence of preterm prelabour rupture of membranes. Delivery is by caesarean section, traditionally by classical section as a permanent isthmic suture is placed at the time of trachelectomy, but nowadays a transverse incision may be used to reduce morbidity and the implications on future fertility. Learning objectives Management of a pregnancy following radical trachelectomy. Intrapartum care of post‐radical trachelectomy pregnancy and complication risks. Impact of trachelectomy and subsequent pregnancy on the woman. Ethical issues Informed consent surrounding trachelectomy and future pregnancies.
Plasma cell myeloma (PCM) is an essentially incurable neoplastic disorder of terminally differentiated B cells. The neoplastic clone usually secretes a monoclonal protein in the serum or urine (the 'M band'). About 20% of PCM secrete light chains only, which are detectable in the urine as Bence Jones protein. The clinical picture is one of bone marrow failure, due to infiltration of the marrow by malignant plasma cells; renal failure due to damage to renal tubules by the excess light chains and pain due to lytic lesions of the bones. The outcome remains poor with median survival of 5 years.
Gonadotrophin dynamics in women receiving immediate or delayed transdermal estradiol after oophorectomv. Obstet Gwiecol 1991;78:98-102. AUTHORS' REPLY,-Our study showed significantly higher concentrations of gonadotrophin in oophorectomised women treated with the 0 05 mg oestradiol patch than in those given a 50 mg oestradiol implant. As stated in our paper, we think that the lower gonadotrophin concentrations in the implant group were due to the higher oestradiol concentrations observed. Unpublished data from this group of patients at 12 months show significantly different oestradiol concentrations: a mean (SE) in the patch group of 224 (43) pmol/l and in the implant group 544 (42) pmol/l (95% confidence interval for difference between means -443 to -197, p<0-0001). As stated by Stevenson et al, patches have been shown to prevent postmenopausal bone loss, as have implants,' but it has also been observed that percentage increase in bone density correlates with plasma concentrations of oestradiol,' and so treatments resulting in higher oestradiol concentrations may be more effective in preventing this long term consequence of the menopause.This suggests that Eliot et al may not be correct in their assertion that serum oestradiol levels greater than 120 pmoUl provide no additional effect. We agree that implants should not be forced on postmenopausal women who are keen to have patches and vice versa.Reid and Ganger question the ethics of our study. Delaying treatment ensured that all women had equivalent baseline hormone profiles before starting oestrogen replacement; given that one of the aims was to compare hormone profiles, this was a necessary part of the study design. They also question the doses used in this study: we did not set out to compare equivalent doses, but rather, the recommended starting doses. Careful reading of Chetkowski et ars findings reveals that transdermal oestradiol significantly decreased gonadotrophin levels in a dose dependent manner.' Kamel's paper referred to administration of the 0-2 mg oestradiol patch immediately after oophorectomy; suppression of gonadotrophins was not maintained.4 Our study showed that the 005 mg patch did not suppress gonadotrophin release after oophorectomy (mean concentration of follicle stimulating hormone after oophorectomy, 37-3 IU/l; after four months' treatment, 53 4 IU/l). Although there is no evidence from studies on the long term benefits of the 0 05 mg patch compared with the 50 mg implant, our study shows that there are differences in gonadotrophin concentrations which we suggest are due to differences in oestradiol concentrations and which may be reflected in the long term benefits of oestrogen replacement therapy.
The National Health Service (NHS) response to the COVID-19 pandemic brought about rapid and innovative changes to surgical care in gynaecology, shared decision making around operative procedures and pre-operative gynaecological pathways. Short term changes are linked to the redeployment of resources away from elective gynaecology, longer term changes relate to accelerating the streamlining of treatments, telemedicine and education in patient self-management. The speed and recency of the response does not yet permit the creation of a large evidence base for effective and acceptable interventions, apart from anecdotal observations of ‘what works well,’ good practice and guidance from the Royal Colleges and the National Institute for Health and Care Excellence (NICE).
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is rarely seen in women with ovarian teratoma. It is characterised by neuropsychiatric symptoms and may also cause autonomic imbalance. We present the case of a 16-year-old nulliparous woman who presented with an acute history of seizures and neurogenic bladder. Antiviral and antiepileptic therapy conferred no therapeutic benefit. A cystic pelvic mass measuring 185×140×92 mm was identified separate from the bladder. Serum titres of NMDA receptor antibodies were significantly elevated. The mass was surgically removed and histology revealed benign ovarian teratoma with NMDA receptors. The patient made a rapid improvement and had full resolution of urinary and neuropsychiatric symptoms within 1 year. This case demonstrates that increased awareness in adolescents is crucial for avoiding symptom dismissal, misdiagnosis and inappropriate treatment of this condition. Surgical removal of the teratoma should be the first line therapy of anti-NMDA-receptor encephalitis as this often leads to symptom resolution soon after.
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