(I~l\e 11rearleslhetic c()l1sultati()l1 (licl11()t fil1tl arlY cl111lraillclicat ...

Ill()\.Jilc \vit.h resl1cct lc) tile c1eCll 81\(\ SlllJcrf-icial slruclllres. rrllere was al11()l)1 le l1Ut very tCll(ler axillar)1 1)/n1r)ll 110clc. ".r11ere were 11() slll)raclaviclllarI)'lllr)1111C)(les. ''J'he llcart nnd )\Jllg exall1irlatic)11S ""ere allllorl11al.'rllcrc vvas Cl slll) lll11lJilical 111i(llillC scar but tile al1

11(Jst.()j1erative ev()luti()ll vvas lllleVelltll..IL '~rlle ()atierlt was tiletl reCerrecl 011 tIleJ ()tJl r)()st()r)erntivc

11regnaneies. rrhis is ill Slllll)OI"t ()f t.lle fillClillgS of L)oll et al tllat 11l11li.l)arity isless frCC]UClll tl1all 11111Iti)Ja.rit.y as risk. f~lctor ill Ollf ellvirolllllellt (6).r.~ll\'ir()IlIl)enlal risI< f~lct:l)rS illClll(fe irracliatic)11, ()l)esity, CllrC)J1ic stress,(lecrcHsc(J J1J'1)/sical act.i,'ity, 11igll alcl)ll()} COllSUll1ptioll, 11igller socioeC()n()lllicclass, lligll Ic\!cls err clietary fats, al1(1 l)reviol.lS l1istory of breastcallcer (4). ()ur IJatiellt \\'HS ()lJese alld was ill tile l11ic)clle soci() econol11icclass. It is IlOW \vell estal)lisl1ccl tllat llorlllollal factors stlc11 as ()ralc()nlracCl)li\1CS ntlcl 110rnl()11C rCIJlacel11c11t tllcraI)Y increase tIle risk ()f l1reaslcallccr. llc)wever, SOlllC Hllt11

'rile clil1icia11 sl\()l.I1

l>r()grl()st ic facl(1rs irl tJ1C treat11lcnl C)rl.>reast carlcer are 1)Ot1-1 11re()!Jerc\ti've all(1r>IIsl()I)eralive. I)re () rle rative I~J etf)rs (11al er) IIrer !)() 0 r 1)rog 11()si s are t11eelinica1stage, l)ilatcralislTl ()f tIle CHl1cer, )'()l.1I1g age, anti clelay ill startil1g treatlllcllt,ral.11cl gr()wtll ar}c} tll1110llrs ()f tIle illterJ1al cluHclrat1t e)f retroareo]ar regioll (10,1J). [>()sl.C)l1erative fa(~t()rs irlclicatiJlg a })oor 1)fogll0sis are a large tll1110l1fsize, axillary inv()lvcJllcllt, I)()()rly clirrerelltiatecl !Ulll0urs U11cltlle absellce ofoestrogell reccl)tl)rs ill t1-le t.Ulllclllr SIJCCiJ11Cll. AltllOUgll tllcre ,vas axilI,lryinv()lvCll1Clll., tIle (Ulll()Ur was well (lifTerelltiatecl iJl Ollr case al1c) it ,\fasl()catc() ill tl'lC l.J O(~.'-rrCallllCJlt ()r IJrenst callcer C()l1sists ()f l)()tll loco-regiollal (1 11cl systelllictreatnlcll1. IJ()c()-regic)11al trealt11el1t Cl)llSists ()f sllrgery allcl racliotlleralJY\\Vllile S)'Slelllic treatJl1eJlt. cOllsist.s ()f ClleJllotlleral?Y Cll1cl11orll1011al tlleraj)y.ISurgery c()ltltl liC cOllservative liJ(e quaclralltectofl1y, or raclical like ra(iicalITIHslectcllI1Y 811(1 axillary clearallce. ltacliotllcralJy is illclicated if tile first\ .level of Berg's nodes is positive or if conservative treatment such asqllatlrallf.eclonlY is llsed. It retlllces tIle risk of reCllrrCllce by 75% (4). Failllre()f )()c()-regi()llal trcatlllelll is eXj)laillec) l)y tIle fact tllat t11ere are 111icrolllct.astases lJreScllt l'>efC)fCt.lle breasl cancer l)CCall1e clillically cletectable.'"rllis illlj)lics we neecJ to atlcl aclj\lv

l)()or 11r()gtlc)sis; ()tller\vise Cl1Clll()tllcral)Y is carriecl ()llt as acljuvarlt treatl11cl1t(i1). ()11 the ()tllcr ha11cl, 11()l"111011()tllcral)Y is i11c1icatecl fc)r 1)()stl11C11l)f>ullsal\,y()ll1en ()r Wl'lCll tIle Il()rU1()nal recclJlors arc l)reScllt. It COllsists of eitllcrHlllieslr()gens (taJI1C)xirCI1C), L~tl-l~l-l analc)gucs (tril)torelcllc) orHJ1ti£lrOJllatascs (e.g. anastrozole, letrozolc). l)r()gestillS(1l1cclr()xYl)r()gesler()11C acetat.e) are 110 lC)11ger reco111111ellclecl becallse sorl1el)reast carlccrs flare UI) witll tIle llse ()[ IJrogestogeJ1s. Otller 11ew 11101eclllesillClttdc; 'rratazlIlllal) HnllC. 'l~hey are classilieti as S'T'f~A'R 111ea11ing:Spcci fie 'riSSllC [i:slr()gcllic Acti()l'l IZcgttlnt()r.'rreaLJlICIll (~clltcrs vary ill the }Jfccisc schceJll1irlg ()f ))()st 0IJeralive foll()\V- UI1nppoinlments, but the gencral trelld is to reduce ,the frcquency of clinic visitsuntil finn} cfiscllHrge aft.er 1() years. S()111C alltll()fS !)rOll0Se visits every 3Im01l1 hs 1'01' I yc;]r (plus adjuvanl treatment), theh visits cvery 6 months for 4yenrs, (\11

1_ AI1ClcrSCl1 l'-l(), Sllyyall r~) l~rlill A, et al. IJre,lst callcer III liJl1itelireSC)UfCeCOlllltries: all ()vervie,,, (Jf tIle .f3reast l-lealtll Global Illitiative20()5 guiclclincs: I3reast J. 2()()(j JaJl-l~el); 12 StJI)lJll:S3-15. [I>ubMe

MANA(;lT,IVll~N'l' ())T (~EI{·VI(=A·l.lC~ANCI~It S'I'AGI~ III llYI{AI)I (~~A l.J 11 Y~r'I'lGlll~(~rl'()I\lYI)a(ie11 t i(I (~ 11 tilicati() 11NanlC:Age:I\1rs. [l. J\.48 )'carsMntri III() 11 i(\1Stat11 S :l~esi(le]1ce:J)I"() ressi() )1:r~ tI \ni ~ gr()III):Itcligi()Jl:t\1 aJ'I~ie(1J)j anlCl1a C~lla(iI·I() t1se \v i ref\1assn(~~atllt)]icA(I '[I'C'(·l'·~ -'/,,)l_'.(-J () I)(l () () ()1.",[\/1 l':I)ate ()r 1\ (1, rlissi() I}:28/()2/2'()() 51()/()3/20() 5M ni 11 C() lIlt)Iai 11 tSI1C was refcrrct) l1y a CjyJlec()logist 111 Cll(lcl ['()r Ilavil1g a. cl il1icallyStlSJ)IC1()lIS cervIx.I1 is t() ,.y () f t11 C iIll. CSSr'l'hc r)aUcnt C()llstdtc(1 a (J)/11eC()1()gist ill l)julllcl1a for a rOlltirle Cl1Cck.lll)fc)ll()\ving a laIJarC)(o111Y fc)r ()\'ariclll cyst a )/ear eclrlier. I)llril1g tIle I)llysicalcxa1l1illali~)11, tile cl()et()r rcalize(l tllat tIle cervix ()f t11e 1)atiel1t wasa!)1l()1'1l1H I] y enl ar!~c(1w itll increaser) ,'asclllarizati ()11. Ile clccicletl to refer tIle1atic 11 t t.() us Cl) r J) r() 11CrillCl] 1ageIIIellt.(';YI1(~(~()I()gic~llllis()r)'SI'le Ilatl t\er 111Cllnrchc at 13 years (11'1(1 llcr first il1tcrcOllrsc at 15 years. Sllewas l1avitlg regular 111enstrual cycles ()r28 (lays ancll)lecl for 5 liCl)/S. Slle llucl257

ink.ell il\jectal)le c()ntraccl)lives f()r tile past 4 )'ears. rT'llcre was 110 llistor)' ofsextlully tranSlllissil)lc illfectiorl. SllC l1uclllever C]Olle ,1 Ilaj) S111car before.()llstetrie Ilisf()rySI-le \\las Cjrnvicla 6 allcl )lacl cleliverecl 6 ballies at terr11. rl'11e first cllilc\ was 30ye Clrsol

W()r)"illg (Jiat~ll()sis'rIle (lingll()sis of l)r()bal)le callccr of tIle cervix at clirlical stage 1132 wasll1[l

11alicllt \vas ctisellargc(1 ()), tIle 1()th tIny l)osl ()I)Cratiol1. SllC was reviewecl ,1\vecl< later vvitl) tile res\.llt of' llistulog)!. It. cOllfirll1cc\ tIle illit.ial (liag11osis of'cervical (\11 ll()clcs vvcre Ilcgat.ive.))lSCIJSSI()NCallcer of tlle cervix Hll(1 breast ca11cer are tIle Ill0St Ct)11111l011 gyll(lCcologic£llC8Ilcers ill ()tlr Illilicll as S110Wll l)y Ml)akol) et al. ill 1990. 'l'llC bllrclel1wor)ti\vidc is 11ca,'y. 170l1r 11l1nclrecl al1cl 'fifty tll0tlSclllC\ (ll50,O()()) l1e"v casesarc (lint~l.l()scll cuell year H11

nssc)cinted \,yitll tIle risk_ ()f tlevcl()})ing cervical callcer. A rCCcllt stllClycstinlatcs tile \v()rlcl-vvi({e Ill?V I)revalel1ce ill cervical cancers t() be 99.70/0(7).'1~11c rCl1ro

1)reVcl1t 91 (x) of' cervic.al callcer. WllC11 associatetl \villl VIA wllic11 is Cl()11eevery 2-3 )'ears, tile illterval ()f [>ar> S111eclr ll1ay be extell

--'_.__._--._----------~. __'rreallllcnl ()l)ti()I1S r

Follow up include regular visits every 3 months for 2 years, followed byevery Cl months for 5 years and then yearly. During each visit the history isrevicwcd and clinical assessmcnt carried out. Para clinical tests for followarc Pap smear cvery Cl months, yearly chest X-ray (13, 14). VIA can be lIsedinstead of Pap smear. CEA and SCCA can also be used for follow up. Ourpatient was rcfciTed back to her gynaecologist for follow-up due to thedistance alld finances involved and had to report to us aner a year forcontrol.The n1£1I11 prognostic factor in cervical cancer is the FLGO stage. Insurgically treated patients, the most important prognostic factor is the lymphnode status. The lymph nocles were negative in aliI' patient, and therefore theprognosis was good. In gcneral, the 5-year survival rate for stage I disease isIabove 90 1 %, for stage 11 is 60-80%, for stage III is around 50%, and for stageIV disease it is below 30% (2).Cancer of the cervix remains a major heallh problem in our setting. We praythat the effort being put in by the permanent secretariat for fight againstcancer should be encouraged by the decision makers. With this steam therellJay be hope one day for our women.264

Ill~~/lt I~IlE: N

12. L)()ll AS, CJ1()lIl1Ct()11g VN. l)olllJle l)rilllary Illalig11a11cies il1 flat.iel1t.s witllgyllaeC()}(Jgicnl CHllcers. }\[r J !{.erJrc)clllcaltl1 1997 Sep; 1(2):96-1 0211. Y l)tlli. J., C_i l\1()1\l

]) ~, fie 11 t I (I C11 filiC~l ti() 11NaI11C:Age:Marital slatl.lS:;\r() fessi() 11:(~J 1.1 1)() ()4 ()Mrs. N. J--I . .I).33 yearsJ\1arriet)SecretaryI_J NIl): ] ()/()]/2()O 5i\ (11)1 it leel:1R/()4 /2()()5My()111cctorny: 19/()4/2()()5.I)isell argc(I :2 C)/ C)il/2 () CJ5Sec())l(1 1()()1< LJHJ1Hr()SC()11)/: I()/()S/20()5.1\1 ~Ii 1I (~: ()1111)I~1i 11 tSl1C c()Jlsldle(1 f()r l"lC8VY l11Cllstrual flc)w, sel1sfltic)fl of wCigJlt ill tile llelvis(lll(l illnl)ility tt) concciv(~ f()r tIle l)ast 8 years.I1 is(()I·y ()f (Il(~ illll(~SSThe patient has been ullable to conceive for the past 8, years despite regular11()l"lllal seXIHll illLerc()llrSC, 2-3 tiJlles wce){ly. Par tlle l)ast 3 ye

(~~)')I CC()I()gicaI 11 is t() rySIle )1(\(1 I'ler JllCnarc)lc at 14 yeClrs arlcl l1er first co jtllS at 15 ye'\rs. []ertllellSlrual cycles lastctl 26-28 (lays HJ1(1 SllC Illcrlslruutccl l1eavily f()}" 5 ({'lyS.SI'le WHS havillg sec()Jlclary dyslllell()rrllea allc} (iee}) (lysl)arellt1i'1. Sile llaclllevcr tak.cll 11()rJll(ll1nl cOlll.raCClJtioll ancl l1ac] never 1)eCl1 screellccl for callcer()f tile cervix.()Ilstcf rica) I,is()rySllC "vas gra\/iCJel 4, 11Hclllever carriec{ allY IJregllHllCY t() terlll, arlcl YOllll1tarilyterJllirlatccf 3 IJregnullcies ill tIle first tritTlcster \vitll 11 C) COl11plicatiollS. Slle11(1

W ()r){illg ].liagllf)siSrrllC (liagJl()sis of )10Iy111yolllal:()llS llter\lS 011 SeCofldary i11fertility was fllclc.te.()ur (Iiar~n()sis was C()nfirlllec.l l)y llll:raSC)l1l1Cl vvllicll iclel1tifie(i severalJll)/()lllHS Wit.Jl S()111e cllcr()(.lclliJlg tIle en(IOlllet.rial liJlillg. A11ystcr()salr)illg()gralJI1y Sll()\·veeJ a single tllbe 011 tl1e left lllUt was clistallyl)l{)cl(ccl anti Cl llterillC cavil)' tl1at was ()ccll!1iecl l)y 11rl)1)al11)' SO.l11e l)f" tIlelllY()111HS. 'l'llc }lusl)aI1(1's Sr)erlll allal)'sis \"Ias witlli11110rJllal lill1its.1\1 nil a gelll {~Il ('I~lle I)rc()}')erati vc W()rk.11l1 Sll()Wc(1 al1 I-Il) level of 1l.2;g/(II, 110rl11al I(i(ltleyfUll eti() 11(cs1s (\ 11 (I g() c) cl cI() ttillg r} r()It Jc. She was l--IIV 11Cgative. S11e W,lS 0 fblood group 0 rhesus positive. Iler fasting blo,od sugar was 0.78g/dl. TheI)renl1cslllctic C()llStlltatioll f()l1l1(1 11er fit f()r ITlaj?r sllrgery llr1cler gel1eral orrcgi ()JlHI allestllcsi(l.rrwo )lilltS ()f l)lo()(l were reservccl le)r tIle sllrgery. 'l~he()!)Cratioll was Cl011C(JIl 1~)/()L~/2()()5. f'v1y()nlcct()111)' \vas achievecl tllrollgll a 111iclljrle Slll)-1l111bilicalil-1Cisic)11 f()llc)\ving all ()lcl at)(iOn1i11al scar. l\ tOllrl1icluet was IJlacecl 011 tIleistlllllllS () rtile \I t.Cl"llS l)e {'C)re st.arting the erlllcleatiOl1. Snli S{~lctoryIlenlostasiswas acllicvc

l'J1e I)atierlt C()llCei vecl 3 1l1()11tllS af1.er lal)arOsco11Y llnfortllllately at 8 week.s()f' gestatil)rl tIle fetlls was rlot vial)l(~

s))()nt.allec)us ~·.dJ()rti

Illl.IC()llS Ill)'()lllHS less thall 4elll i11 greatest clial11etcr, llysterC)sc()!)y isrCCl)lllllle.llClctl for 11igllly sl

1. (~:()tllc)/ (]. I-IHcey. I)elli!~ll clisorclers of tIle tlteriJ1e COfl)lIS. ]r1: C:llrrCJlt()IJstctric 811(1 (]yrlcc())()gic [)iagrlosis alltl treatll1ellt. Sevellt:lll~(J iti()l'1, 1991. l)agcs 732-1""138.2. C~rHlllcr sr·, llatel A. rl'lle CrC(llJCI1CY ()f uteril1C IciolllyOl113S. All1 J Cli11I)atIl ()1 199 (); 9Lt: Ll3 5- {~383. Ngallg [)l2. 1-1)'stcrectC)111y: A five )'ears retr()Sl)ective rCVle\v III'J' a()Ul1de. rl'llcse (le MCllecine. li'l\/lsn UY.I.4. I-IassOJl I-Ifvl, r{C)tnlarl (~~, IZ

C()NSI~Il." ArI'IV]~: MANA(~EMl~Nr'r O'F AN AI1I)OM1NALr.r'I~X'l'II.J()lVIAI)afieI' t i(ICl)tinc ~l t if)11NalllC: Mrs. (). A.Age:28 yearsMalritll()]lial Status:l{esi(lcI1CC:l)r() fcss j()ll:Sillgle13iteJlgrrrac)crr~ t11 nic gr() 1I J):I"{ eJigi() 11 :A,

Tv'fecl icn I (=~al)itlet in t()\VI1. ",rI1C resu It i11Cl icatccl a ttlb

l~"\i 11 (I i ItgS () 11 ()I) )'sicaI I~x~. IIIi 11 ~\ l i() 11Sl'lC was acutely ill-lool

1\ repeal vnginal examination found a long and anterior uterine cervix and apouch of Douglas filled by a textile mass. A rectal examination found atextile f11HSS 11rl)l.rll(lil1g fr()111 tl1e l)eritol1cal cavity iI1t() tt-le rectal ItltllerltI11'()llg)1 Clfislul,l (lll tlle arltcri()r rectal wall. 'r'lle lnass W,lS extrf\clccl dllrillgthe rectal cXCllllinatioll allt} it call1C Ollt to be al)(loI11ill(11 gallze. IMCJelltalllicil1e 8()rrlg 12 IlC)llrly \'Vas [tc)cletl to 11cr treatlllellt.L.lat.er ill llle (fay, S]lC clevel()11ecI a fever \villl cl tCIIIIJeratllre of 40 clegrees(~elsills.l31()()(1 SIJccilllell \\lns c()llcctccl rC)r 111alaria I)(lrasite exalllil1atio11 aJlc!tllCll 1V (~1l11lirI1Hxt1D 50()111fs 8 llourl)! ass()ciateci witll IV l>aracetall101 ]g 8ll()tlrly (,(Itlec) t() Iler treallllcllt. SllC \vas afel.Jrile 2L~ llollrs later l)lll 111alarialreatlllelll ,"vas c()]ltillue

) I S(~~ {J SSIl)N[)cSI)ile all tIle l)recautio11S (ttlring sllrgcry, it Illay l)e Sl.1r[lrising t11atf()rget.ting Cl C()ll1IJress or ()f a Illesl} rClllairls slill I)OssilJle (1). lI()wever, are1.aillC(1 sUl'gicHI sl"Jonge (g()SS)'I)il)()Jlla., textil()f11

al)(lc)]11iI1C:ll ult.raS()11()graI11ly Sit~llificallt.ly inlrJr()vc(l tIle l1rC()I)Crntiveclingll()sis, tJIe IllC)sl tYI1ical illlagc l)eirl~~ tllat ()f all ecllogcllic area \villl aI)()slerior S)lHeJ()\,y C()lle. A.l111C)ugll tIle ultrasOUllcl il11age is llC)t. sr)ecilic, it is11cvcrtJlclcss enc)l.lgl'l stJggestiVt~ err tIlC (ii ngllosis () f texti lOllla al1cl tlll1S foril1(licatil1g all c

1. l3az l~, SllceVCntll1 1), l)()iceSCll I). l)iagl10sis of text.iloll1as. Ctlirurgia( 1311CII r). 2() () I Ja11-1"1e1); 96( 1): 59 -6 1.2. 'l'()l)al tJ, Sahill i'J, CJok.a1l) C], CJclJitekjrl C. Illtralll0racic textiloll1clS:I{u(lic)()gic fill(lirlgs (case rel)()rt). [Article 111 'T'llrl(jsll]. rralli Girisil11l~a(I)'()1.20()4 I)cc; 1O({~):28()-3.3. .I-.JC Neet JC~, [)e Cllssac J13, I)l1l1as 13, I..Ictessier r~, I.3ofcle L, I~l()llfir 1\1,Arlrlstr()11g O. 'rextilollla. ./\ l)r()!)()S of 25 cases al1(} revic''V o:f l11eliterature. [Article ill r;rCllcll]. (~11irl1rgie. 1994·-1995; 12()(5):272-6;(JiscllSsi()n 276-7.4. I1Cl Jrllll() II cl [), i\111111 () 1.1riN, I~ 0 r111 Cl rla G, Saa(1 I-}, I-I IIsseilli 1-'1, At)() 1.1Sleiman C, Haddad M. Imaging features of re~ained surgical foreignl)()({ies [A rticle ill l~rCl1(:11] ] l~a(li()l. 20C) 1 A\.lg; 82(8):913-6.5. .I(,{)l)kn I.~, r~iscllcr lJ, (Jr()ss .AJ, r·ullke lVII, (1estlllallll lW, CJral)be J~.(=~rr\ ()f retainer] surgica.l Sr)()llges (text.iloll1HS): l)itf~llls ill cletectiol1 alldcvallHlti()1"l. J C~()flll)ut Assist '['()Illogr. i 996 N()v-Dcc; 20(6):919-23.6. Vatl (J()ct.llelll .lW, l)arizel f>M, 'Pcrcliells r), lIerJl1Hl1S .1), de Moor J..MIZ 811(1 (~"rilllagitlg of j1arasj)illal textil()llla'(gossYf)iboflla). J COJ11PlltAssist'rC)1110gr. 1991 N()v-T)cc; 15(6): lO()O·-3.7. Slanciu C, Frasin M, Balm) G. The value of' the echogl'aphic exam intile ctingll()sis (lC irltr'1-ab(I()1l1irlal lf textilof11as". [Art.icle ill Rorlla11iarl]Rev Med ChiI' Soc Med Nat Iasi. 1991 '~!111-Dec; 95(3-4):269-72.H. f\1()uhsiJ1C 12) CJar()falo l~., (~~i](es 1\., l.Jeyvraz I)F. [-Jeg,textilolllcl. A caserel)()rt. Me(} l~rirlC l)ract4 2006; 15(4):312-5.280

ItU I)'f'lJ 1{.I-i: I) I{ IC; 11'1' Al\11' UI-JlJA I~Y l)l{I~(;N j\NCY: ll.1 (;11'1' rl,()rl'Al_~SAI.JI)IN(~Ecrr'().l\/IY·.]l ~ltic11 t i cl e '1ti ficati() 11NanlC:Ivtiss N. M. l_~.Age:23 years'Malt"il11011ial St.attlS: SillgleJ{csiclellcc:I)t·o fcssic)Jl:f2tllllic grolll):rZcJigic>ll:!\(I(lrcss:r~SS()~SCHll1Stt'CSS[~WC)lleloC~(\(Jl01icy (1C)l1Jlclc("2.1)() ()2()l-,MI):14/()1.~/2()()609/0()/2 () () ()!\JllCI1C)rrl1Ca ()C 8 week.s.r)ate ()r I)iscllargc: 16/()6/2()()()I\1 a ill C() 111()Ia ill tSI1C ,·vas rllShe(1 int() tIle clllcrgcllC)' UI1it err the CClltral fvlaterllit)! l'la\/illgcollapsed in (he workshop and she also cOlllJ?lnined of lower abdominal pain.11is t() ry () f t 11c iIJ11 CSSS11estarte

al1tl Cell ()Il tile fl()()r. I ler c(Jllc(I!~llCS ()f tile \v()rl

ITill

l)I'()t of ect()})icl)regllancies ()CCllr ill tile tlteril1e tlltJes. ()llr case was tlll)al. Sevellty fivepercent are diagnosed before the 12''' week of gestatiOl~. The case uncler

) reg,l~ct()I)ic 11rCt~llallCY Illny ()ccur at HI1Y til11C 11'()111 llle11arcl'le to l11CnOI)atlSC, l)tlt40

wJlcre tIle facilities are reallily availal)le, tIle stalllS of a tul1al11regllcu1cy calll)c IJrcclicted relialJly ()ll tl1e l)asis ()f trallsvaginal s0110grn])11ic fi11Clil1gS (8).l"'lle classical clinicnl ])ict\lre is llsllally; SylllptOll1S ()f early l)regl1aJlcy(alllel1()rrI1ea, lJreast 1ellf)erJ1eSS, ancl llallsea) a~·e [oll()wecl by bleecling(usllatly S11t)lliJ1g) ancl diffuse lower abclolllirlal pai11 \vitllil1 tIle fir~t 1-8wecl

tllt>al rlll11ure, a1'\

~_",_. .-o_._,~ .","..-----_.__._.._--_...._-_.~-_._-_--.._ ..._---~-~--------~-...._._~ ..----_...__.__..._l'\~ll)lc 1. rfcrll~'ll('CZ Sl~()rCSc()rcI)n .·n IIIet Cl" 1. 2 3. ....__..... .... ...__- ... __ .._..~ .__ ,~ ~--_. __.~ ..------------....--------------- ---------------All1CI1C)rr)-aea ((lays) :>49 42-49

case, as earl)! as t11c ell1Cr!~ellCY lal)arot.c)111y f()r SllSI)lC10ll of llllrl.l}1tllreclect()IJic. J1rcgnnncy c()llfirn1cllS ()ccurrccl 111 tl)al series (18).[)l.le t() tile }()wer IJoslc)11erative tlllJal occl"USiOll rate arIc} lovver tenclellcy toaClllCsi()ll, it a[)IJears tllat tIle laser syslell1s are sllperior to tIle convel1tionalCllcIOSCOI)Y il1strunlel1ts, altI-l()llgll tIle rate of COlll1)licatioJ1S was 11ig11est after(~()2-1Hser HIJ111icati()n (] 9).(),(Jerative }1elvisco}JY Slll)still.ltes at tIle !)cl)arllllel1t of Obstetrics alldGyllecolc)gy, Ulliversit.y of .I

1. Saxoll 1), r4'alc()1'1c "]"', l'v1asclla r~J, Marino rr"', y'a() lvI, "·ftllallcli r!,. 1\stll(ly of rtl!J{llrCll tul)al eclOl)ic IJregrlallCY. ()bstet (:JYIleC{)l. 1997 Jlll;9()( 1):4 G-~). (~0111111Cllt ill: ()llstet Gynecol. 1997 Nav; 90(5):866-7.2. Oll (:S. t.lfllJar()sc()}Jic 111Hl1agcll1c11t of ectolJic l)regll'll'lcy. J ]~el)rodMelt. 1993 N()v; 38( 11 ):849-52,.3. C:urrcllt Obst.etric 811li Gynec()lc)gic I)iagr\osis antI rl'reatl11ellt. Severltlll~(liti()Jl1991. MartiJl 1..1. I)erll{)ll, MD.LI. J~aIC()llC '1', I\;Jasc)la l~J, (]o)(llJcrg JM, j7 aIC()lli .t~L~) I\lc)}llrl G, Attaral1M. A stll

SCUllCl. 20()2 "N()v; 81(11):1()53-9.I I. Il}nrlC)lCr S, (~()llWa)' (~, Znlt.l() I. rrrallsvclgillal c()lor l)olJplcrultras{)l1l1cl in tile COllscrvative treat111ellt allcl Sllfveillallce e)f lllreeecl()r>ic J1rcgnancies. C:rc)at Meet J. 1998 Jllll; 39(2):216-9.12. l{oI11er'T', (iralJow I), 130jallr 13, Ml.lller J. lIysteroscopic trcatlllellt ofttlball)regllHl1CY by il1lr,ltul),11 illjectioll of l11etll0trexate. [Article i11GcrlllHll]. Gel)urtsllilfe PrallCtllleill(cl. 1996 Se}); 56(9):470-2.13. 13ellifla JJ .J' SelJL1an l~, l)erlllellOl.lClt G, I l rOl.lst. A, NaoLlri M, Creqllat J,MatJclcllat. 1>. rrreatlllCl"lt wj tll lllelhotrexate ()f 4 itlterstitial,1I11rul)turc(IIJregllHllcies. [Article ill l;rerlcll] C()11lrace.l)t liertil Sex.1993 Nav; 21(11):8 L l5-7.14. Lecuru ft, Tnurelle R. Non-ruptured ectopic pregnancy. Treatment\,yitll 111etllolrexate. [Article iJl.T 7 rerlcll]. l>ressel.fvlec). 1993 Nay 27;I22(3'7): 1.8~16-9.I15. L,ecllru r:, 'I'al.lrelJe 1(, 13erJlarcl ] I), Vil(ie l~. I{ecurrellt t.llbal .l)regllallCYafter a in1ra-ltlbal illjcctic)[l ()f 111et110tre(Cute. AJlalysis of a case rel)()ltwil.h a histological tubal study. [Article\in I'rench]. J Gynecol Obstet11ic)1 I{.el)r()(l (l)aris). 1995; 2 L l(5):482-4.I G. ()eIsncr (], (]()lclcllIJcrg M, !\ctrl1()11 .D, l)anslaris). 1978 ()Ct-N

2(). f\/lclt ler 1.../, SCll1111 1(, IJiagll()sis HIHJ cOllservativc lrefltrllellt of tul-),llr)rcgtlancy 11Sillg, ))elviscOl))' ill C.Ollll)aris()ll ,vitll Ifl})arotoll1y. [Articleill (]erlllan]. (jcl)urtslliIre 1 7 ral.lel1l1eill((l. 1987 ()ct.; L~7(10):717-20.21. J')aaV()I\CI\ .J, \lulj()11Cll-r'roiv()llCll 1\1, t(JlI1Ulairlcl1 M, I leill()llCll t)l

.IVIANA(;I.~MI~N']·' ())? Il\'I)A'I'II)IF()l~Ml\1()I.J:E DV MANUALIN'l'll.A lJ'~I~I~ltl N I~ASI)IItf\']~l()NNallle:Miss 1.J. 'f'Age:19 yellrs.Marital status: Sillgle]lrofessioll:1-] igll SellO()I SllJtlcJl t(] I]>()() 1()l~MI) 11/()2/20()4·AIllerl0rrllea ()f 8 weeks./\

, ~:CyuN:otogh'fll hisforyShe Iwd her menarche at 12 ycms nlid had th

ges1at i()ll. 'rhe arlllCXCS HJ1

l()t or err~Jl't ()]l c()llnsclin~~ tC) g,ct tt-le l)at'iellt (l() anC)tl1er lest. 'Tllat "Vlas C\()llC 5vveeks later (\n(} was still less 1.\1a11 \ ()\.J1/1. We ()111y sa\\' t11e 11atiellt RlsaitlaCc()nll)nllyitlf~all()tller l")atiellt {.() tIle l-\()srlit.al Hncl slle achllitt.e

(.lilrlellSic)llS. lllcleecl, tIle l1alrle tl)/ctaticlif()rlll 111()le is dcrive(l frOlll tllis 't)tll"lcl1()f gral)CS' nr)lJCararlce. [~,'ell tll()llg,ll tIle vesicles were fc\¥ ill ()llr case, tllCyc()l.llcllJC easily i(lclltificcL Mic.rosc()})icnlly, tIle Cl10ri()11ic villi are l11arl11.s. 'T'lle cisterll tnay beless well formed with the development of a Ipaze-like pattern. Normal-sizedvilli are })reserll. '['here Illrty lJC eviclcrlcc ()f f(~\t.al clevclol)111cnl. 13100(1 vesselsCOlltnillill[~fctal re(t l)lc)()d cells l11ay be ctetectccl. 'l'lle patterl1 ()f trop110blasticllYl1crJ1)asia 1l1H)f 11c]11 tc>llist.illgLJisll a l)artialll}()le [rC)lll a Sirlll)le lly()ro!)icnl101tiofl. ]r1 J1artial 111oles, tl1C villolls trOl)1101jlasts O'ftel1 s110W [()cal,111ulti f()cal, ()r cirClll11rererltia.l 11r()lifercltic)11 wllile [)olflr e)f lateraljJr()}i ferclli ()ll jS seel1 ifl fi rst lri111esler abortiol1S (2,3).The pathogcllcsis of CrrD especially that of hydatidiform mole, remains aC()I\trovcrsial slIhjcet. Park and Lees attributed the primary etiology to()vcrgr

llydnticli fC)rlll lllC))C is SitrlJlly H f()1111 ()!'" al1orti(}11 \,vitll al)llt1rtl1all)lacelltas tllataTe l)r()11e tr> 111aligl1allt trallsf

E~sti.1l1alcs rC)r the inciclence {)f vari()lIs f()rlllS of gestat.iollal t.rOI)l'l()l)lC:lstictliscnsc vary_ III tIle {Jllitccl f.~tatcs, llyc'lalidif()rl11 111()les are c,l)servecl irl

For paticnts ill whom hydatidiform m·oles are suspected before evacuation,the following tests arc recolll mended (12):• Complctc blood count with platelet determination• Clotting function studies• Rcnal and liver function studies• Blood type with antibody screen• Detcrmination of IICG level• Pre-evacutllion chest x-ray.This is followed by dcterrnination of the risk status of the patient using thefour Bngslwwe progll()~;lic f~lclors (15). These filctors are:• Age >40 years• Oversized uterus• Urinary betn-hCG > IOO,OOO/24h• Serum beta-hCG >40,000 mUl/mL ,• Theca lutein cyst greater than 6cm in diameter• IlypertllyroidismIf a palient presents at least three of these factors, her risk of

or increasing IleG levels are a result of a (~llse-positive lnboratory test resultcaused by heterophil ic 81ltiboclies cross-reacting with the Ilca test.The diagnosis of malignant sequelae as indicatecl by the need forchemotherapy includes the plateau or increase of heG levels afterevacuation of hydatidiform moles as mentioned previously, the histologicaldiagnosis of choriocarcinoma or invasive mole fro111 findings from uterinecurettage, or the identification of clinical or radiographic evidence of/llctastases. Repcat curcttage is not rccommended because it does not ofteninduce remission or innuence treatment and may result in uterine perforationand hClllorrhagc (16).Few indices havc been ('ound to be useful in predicting the progress.ion ofIhydatidiform mole to persistent trophoblastic diseaie. Essentially, the BCGregression pattern remains the most specific prognostic indicator (17).A baseline serUlll lieU level should be obtained wjthin LI8 hours of molarevacuation and followed weekly until normal. Levels should then befollowed every 1--2 months for 3--6 months for patients with paitial molesand ()--- 12 months for paticnts with complete moles, given the risk formalignant sequelae. Our follow--up was not so complete although ourconviction was strong that the patient's evolution was satisfactory at least inour setting with extrcmely limited financial resources.Contraception is indicnted during surveillance to avoid confusion caused byelcvated llCG from intercurrent ·pregnancy. Oral contraceptives remain oneof the sn(csl and most effective means of contraception and may berecommcndcd with no npparcnt incrensc in risk for post molar GTD (9). Ourpatient was placed on oral contraceptive pills.Criteria for the diagnosis of post molar GTD inc.lude progressive nse 111IICO !I..wcl:'>; plntl~n\l of IIC~G IOVe1fl for 3--4 COllflccutive wecks (;1: IO°,.{)301

change); hi~,lologicnl evidence of invasivc mole, choriocarcinoma orplacclIlal-sitc lUlllor; or evidence or Inelaslatic disease (9).The reported risk for subsequent par\inl or complete molar pregnilncy ISbctwcen I(Yo and 2~/(), incrcasing to 28(% aftcr Cl second mole (5). After asingle molar pregnancy, the patient may be reassured regarding thelikelihood of a normal outcomc in subsequent pregnancics, though earlyultrasound is indicated and placental producls should be histologicallycvaluated at delivery or evacuation. An HCG level 6 weeks after delivery is,dso prudent to exclude the rare occurrence of choriocarcinoma.Based on consensus cOlllmittee rccol11rnendatiol1s from the Society ofGynccnlogic Oncology, the International Soci~ty for the Study ofTrophoblastic Disease, and the International Gyndcologic Cancer Society,thc following criteria wcre proposed by 17IGO (1):I) An I-ICCJ level plateau of four values): I 0% recorded over a 3-weekduration (days 1,7,14, and 21)2) An I leG level increase of more than 10% of three values recordedover a 2-week duration (days 1,7, and 14)3) Persistence of detectrlble IICG for more than 6 months after molarevacuat ion.J\ new intrauterine pregnancy should be ruled out on the basis of HCG levels\and ullrasollogrnphy, especially when there has been a long delay in I'ollowlipor scrial JleG levels and noncompliance with contraception.The di:lgnosis or hydalidiCol'ln mole in our selling is easily made. There ishowever a need for a set of healing criteria adapted to our low resourcesclling In be developed. For the time being, managclncnt should lake intoconsideration the individual risk factors and the ability to comply with thetreatlllent.302

1I. 13a!~slla,ve le.[), l)ellt J. a11(1 vVel)l) J., lIyclaticlift1r1l1 1110le il1L~nglall(1 (l11(1 Wales 1973--·1983. L.lallcet 2~ (L 986), I). 673.12. 13rillt()rl I_I.A., J3ralccl1 I\Jl.13. H11C) Corlllelly It.I~., Cll0riocarcillo111,1illcic]erlce ill t.Ile LJ11ilecl Slntcs. A111 J I~I)i(lelI1i()1 123 (1986), 1).1()9'l.13. C~llrr)' S.l-J., I-lar111l1C)n(1 C.C-]., rryrey I_Jo et al., I-Iyclaticiif()rll1 11101c:(ljaL~11()sis,111HJlagcl11cl1t, HJle) l()llg-lerlll follow lll) (rr 34·'7 patiellts..Ol)stet (]Yl1eC()1 ~t5 (19'-15), IJ. 1.l'-l. Sarl

1\/) A NA(; l~ l\11~N'l' ()If "))()S'l' j\ rJ()1{'I',\I .J 1.J 'l"11:){I NI~ }-) .(~.rtlf() llA ~l'I()Nl~ Y I_lA 1")i\1l.(_)l'().IVIYI)atiellt i() ellfifi (~a fi () 11Nanlc: Miss M. S.Age:26yearsrvlatri 111()llinl Sta tt1S: Si rlglel~csi(lcllcc:MelerlJl r() lessi()ll: Sluclct 11.r~thili c gr()IIr):l(.e Iigi (J]1:!\(l0 () 1()LjMI>:l)ate () f (1(1111issi ()11:r~ \\/()ll(I()(~~ Cl 1.110 JicY'1C)llI1(1c.08/11/2()0522/0 1l20()61\ n1en () rrhea Cl f I 1 \'" Ce1< sl)ate ()r l)iscllarge: 09/()2/20()61\1 ~l ill CC) 1111)I~l ill t.Slle Ct)llSltIt.eeJ J'()r j.Je] v j c 11aiIls.Ilist() I"Y () f f Ill~ iIll) ess~)Jletteclnre() tl) llave Clallc.lestinel)! tcrlllillatc(l a 7 week. l)l(l IJregllallcy a111()11tl-l n[~() al~(l site lJlc

Gy 11 C (~ ()I()gic ~ll 11 ist() I ~.YSlle 11(.1(1 )1Cr lllCllarcllC at 15 )'C8J'S aJlcl \vas 11clvirlg Jl1ellstrtlal c)'cles ofvarialJle cILlrati()llS ()f 27-36

"rIle CXHIl1illati()]) lUl()cr Sl)eculul11 sllo'lvVecl a cervical tear 01.1 tIle 11llterior lil)·r.rlle vagirl111 fllllC()Sa. \vas ll()rlllal Hl1(1 tllere \,vas bl()ocl OOZillg ()llt ()f tIle,ccrvienl earlHl. ()Jl tligilal exanlillatit)ll tIle cervix was Jl111g H11C! c) ()sccl allC.!tllere W,lS ccrviC~lllll()tiofl tencterl1CSS. rrlle 110ucll of ])ollgIas was fllll arlcl\'ery len(ler ()Il rectal eXHlllillatit)Jl. Dolll aJ111eXes \vere very tell(ler al1cl t11esi Z,C () f tIle ulerus \vas (Iirfi CtJl t to assess (t ue te> 1)(1ilIS.Iliagr,osisJ\ \v()r]

was clc)rlc. l~'()ll()wirlg tllis exnl11irla1ic)11, a. riglll latcralllterirle l11ass l11eaSllrirlg8ellI 'v\'as (lisc()vcrecl nl",ll iclnz()}c 50()n1g 8 ll()llrly Hl1e) IV i'Io\JalgiJl® I vial 8 110l1rly 811(1 2411()llr IV fltti(ls; IZirlger's lactate lS()Occ al1C1 5tX> l)extrose lO()Occ. I-Ier\I)Ostc)llcrative ev()lttli()ll \vas go()cl al1(1 slle staite.cl ()ral fee(iiJlg by tIle secolldl)()sl()l)cr

llrcvalellce (){" l]()vcrly, illitcrac)', grat'1(1 IlllJltir)urity Hl1(} 11()l'1-lJraetice ofCOlltrnc(~l)li()ll arc Slr()l'lg clelcl'111i11allts ()f illclllcecl al){)rt.ioll (3). 111 SOll1e,series, tt-le 111()St COlll111()11 renS()ll fClf seekillg alJortic)11 vvas too l11arlY c11il(ireLl(59%) fc)ll()wcll l})! illegil~111ate l)reglla.llcy (16~{)) tJrltrai11e(1 provider,restlltillg ill seric)us life tllreatellil1g ir\jllries, IJerf

J)revi()us f~)/11cc(Jl()!~ical sllrg,ery irlc)u(ling terlllillatiol1 ()f IJreg;ll,lllcy, lowerSC[~ll1ell{ (~aesarcan scCtiC)11 HllCl tI\e large 1001) eX.cisioll ()f trallSfc)flllatiol1Z.Olle elf the cervix (1_,L,LrrZ) l)rC)ce(lurc, Wllicl1 l11ay .Jlave rcstlltecl ill scarrillgof t.]lC il1terl1al cervical os was Il()tet) t(> l)e a jJrc\/iollsl)! llllrelJOrtccl risk 'fact{)rfor l.earirlg ()f t.lle illtcrllal (JS leutlillg to [)erf

conl}'")1 icatic)llS ()ccurrecl ill 3 cases irlcluclillg J)arietal itlfectic)ll ill f)ne ease,re I)Cat }1crit() 11ilis rCCll.lirillg re -"() I)eralirH \ in () [1e case, a11cl fa tal i1i() 111ese 11tericill farct i()),l i 11()ne case «)). Our l)alicflt was lllclcy to l1a.ve 11(\(1 ()llly lltt~rirleIJer()rati()ll (llnt was easily rCj1airct{ Hilt) it: )lcale(111Y 11rilllary irltelltic)ll.1..A:lSsey cl HI. itl C.illHlla fl)llllCI tll11t 11011C of t11e !)aticI1ts llscci a l11()clernc()lllracCI)ti vc fllClll()cl ()ver tIle tllree 1110lltJ1S 11receclil1g tlle il1clex pregJ1UI1CYa1'1cl IJosl--nrl)ortal COlltracej')tive cOllllseling WetS illfre(]llent. III tlleir series()ver ~)5% ()f W()lllCrl were self-referrecl t() tl1e I-los!Jit.al at a tilne iJ1tervalrangillg frorll tIle (Jay of tIle IJl'()cc(lllre to 2 111011l11S after al)()rtiorl. l-;'ifty eigllt11erccIlt (58 c yo) ()r I)rcgllancy ternlinati()llS were ])erfOrlTlccl olltsi(te legallydesignated health instilutions and 300/0 were self-in(h~ced.Sepsis was presentill 15.'7(~) of cases fr()Jll ]lealtl1 i11Stitutiol1S ar1({ ,2] .50/0 ()f tl]()se fro 111Iunregislered premises or sel f-induced. or lhe 5 dea{hs in this series (2.4%Ill()rtality rale), 2 invc)lve(t self-·ill()Uctic)ll. (1.1).Although uterine perfralion with intrnabdominal iqjury is a well-describedCOlll)Jlicati()rl ()f vnCllUI11 as.I)irnli()ll (crlllinati()fl ()f ]JregllClncy, 1110St !Jostal)()rli()ll IJerCr)ralillns gjo uJltietectceJ. It is Sl.lSIJCctC(! tllallllallY aSy111ptOJ11aticulcrille l)erfc)ratic)11S rClllaiJ1 tll1(letccte(1. .Delfl)lecl })reSelltatiofl of all aelItecomplication is rarely observed (12). Our case was a delayed presentationl)eC

Suspicioll or ectopic prcgnallcy nlllst always be borne in miml if unduc dclayin their Ilwlwgelllcnt is to be avoidcd ill all cases of complicated inducedabortiollS e~,peciallywhen the patients have risk factors.Prevcntion could best bc nchievcd by reducing unwanted pregnancies bybettcr scx education Hnd access to contraceptive techniques (6). Ovulationreturns soon aner abortion, with half of the women ovulating by 21 daysancr the proccdurc. Immcdiate post-abortion inscrtion of intrauterine dcviccsprovides immcdiate contraceptive protection. Clinicians have feared thatrates of utcrine perforation due to intrauterine devices (IUDs) and expulsionof IUDs Illay be higher in the post-abortal uterus due to its softness ,mclenlargell1cllt. This practice has been shown to be save (1 J).Second-trimester pregnancy termination with dildtation and evacuation(D&E) is associatcd with higher morbidity rates tban in thc first trimester(14). Bladder perforation following uterin~ curettage is rare. Surgicalmanagement is necessary wilh bladder and utcl-US repair (15). In our case theperforation was on the uferus only anu we did just uterus repair.Integrated fami Iy health euucatioll, Planned Parenthood and contraceptiveeducation, a nlass literacy campaign and improvement: of the existingI Inational hc~lIth services me re'comll1ended in order to· ameliorate theproblems or illegally induced abortion in Nigeria (2). That equally applies toour setting.FITcctive and widespread contraceptive use and continuing education ofdoclors remain pivotal if the incidence of abortions and their complicationsare to be reduced (I I). Much has been done in our setting but Cl lot still hasto be done in order to alleviate this burden.Jl2

Il (~l~l~It I~:N (~~ I~S1. J(n.lllbiss Srvl, l·libl)ert .ML~, rv'IaCc,clo11in (~~, I)otter ME. UterillC}lerCc)rnti()ll res\tlting in IJowel iI1f~lrcti()11: S11Cll'l) trullfllatic b()wel ,Ul(}lllCSCll tCl'ic if\j II f)' at tlle tillle of r)regllHllCY terlllil1at.iorl. M i I ·l\1ec.1.2. () () C) JaJ1; 165 ( .1 ):8 ) -2.2. lkecllcl1elu .11, l)k.()li C(~~. I\1orbiclit), a11(lnl0rtality followillg illclllcec\al)(lrlio11 ill NI1C\vi, Nig,eria.r.rrc)j) })()cl. 2003 Jlll; 33(3): 170-2. Li111,,1(. 2003 Ma)'; 13(5):260-2.4. ()jha N, SI1arnlH S, IJal1(lcl J. p()st legalisrtl.i()ll cllallc11ge: l11illil11izirlgl~{)frll)licnti()l1s(If nl)t)lti()l1 l(n(lllllclllClll l.Jlliv tv1c

11. l"n~;sc)1 i\'r. C::rnr)lic(llir>llS ()r ill'..luccd nl)()rti()I'lS (111(1 lIlei)" r)rt~vel\li()l'lS· ('-' I 1"" 1\ f'" 1\ J. J 1 ] lJr() l. 2()0'1 Jurl ;57(5):552-4.

\~;;;;;;;;;;;;.~..:;;;;;:;..-....~~_;;;;;._;;;;';i;;;;=;;;.;;';;;;;;;;';'~~"';;;;;'~~~)i'\';\ I lJ \rl"'I(')N (-)Ii' rI'I,'II-i' 1"I(-i(')I)'·' «-'4"'NA,'1.'(':0--o J , . I __.1 • / . . .,. . _ . ..J ..... H, .JI J. ..:..J._(,)'r~S~l'I~~r]-,Il.1 C AN .[) 1) .It:1)Il\'fIt l (~.I·l(.~)~))> l'I'A °IJ'yA()UNl)'-~) lVI(lDEIJ F()J~ '[,lHe DIA«:.;Nf)SIS OF\",1',,,, '['1 J"11 ()l'JI'}SI . ~I)IT '\...J f .~)._ 1".~ _ . " ~315

I. INTRODUCTION AND BACI(GROlJNDBreast cancer is the IlIost common cause of cancer-rclated deathalllong WOlllCIl worldwide, with case f~ltalityrates highest in low-resourcecOlllltrics (I, 2, 3). One out of cight US \"omen and one Ollt of elevcn toliflecn FurOpcHI1 womcn are affected. The risk increases with agc up to 50%or lIew cases OCCIIITiJlg in \NOmCn older tll;111 65 yems (3).In the USA ill 1991, one hundred n!1d seventy fi ve thousand () 75,000) newcases wcrc diagnosed and the incidence was noted to increase by 3~)enchyear bctween J 980 811

A!)art frof11 irlcrensillg age nrl(1 felllale g(~ll(ler, fal11i Iy llistory is tIle lll()slillllJOrlalll. risl( rac.t()r [c)r breast CH11cer (4). li(llllili'11 risl( factors willC() Il trit) 11 tc 1() ] (Yo risl( J1er year () f S .11()racliceCl t1Cerarl cl 3~) 11e ryeClr () f11Cretlitar)1 CHllcer. 'rIle Illlltali{)Il ()f l.l1111()r sllPI)ressor gerlcs OCClJrS il1 1/400WOJllCI1 ()J1 Cllr()1l1()SOJlle 1.7. 13reast CClllccr al1tigcIl 1 (11R(~A I) Jl1utatioIl willIC(l

grC)UI) aIUt()1I!sI1 it is (he ()111)1 1)l"tJVell effective Jl1CtllC)cl ()f l)reast calleer earlyt\clccti()ll ((».'rile Illtlj()rity ()f LH'cnst tlllll()rS arc l1crligll, c\l10l1t rlO(~!()to 800/0. "T'llC ex,lctil1Ci(tcflce )l()",VeVer e)f l)Clligl1 l)rensl lUJll(}rS is irrllJOssilJle to estiln'lle. rvloststllllies rely (>11 (lata fJ~()lll \V()lllen \Vll() Ilave 11

11'1 J1(11 ients "\-villl L>reast cancer, ll"le scnti11cl 11()cle IS Ll-le first 11()(le ill tIlenxillnry basill t.l)at rccei'ves ltIle 1)rjl11ary l)'lrll)llat.ic fI()\-\, fl.l1d Cat1 l)e llSC(1 tonrenst C

]JaticlllS \vitJ·l l)atll())()gic llilJ11lC tliscllargc (13). "f''lley ·rOllil(i l)reast cal1cer inS(X) ()f tIle 82 cases sl.lldic(1. ~;au1.er f()llll

2. I. 1\1 a i 11 () J. }j {~{~. c.i" c'rC) evalunte the (liagll()slic sLer)S tJse(1 it1 T1(]()l>Y f{))"the (lin!s11()sis (){' t)rea.sttl)]))()urs.2,.2. SIl

e) Study proccdure: Information collectcd from the registers andpaticnts' riles were transferred onto a questionnaire designed for thestudy. The data was thcll 8nulyzccI using the computer software Epiill fo.f) OutcOIne m(~asures were: Dcmographic variables, clinical findings,histology, fi'cquency of various investigations requcsted for diagnosticpurposes and different treatment options.4. RESULTSWe counted 110 eases or breast tUl1lors operated in the hospital from the elateof opcning of the theatre ill 2002 up to July 31 si 2006. We could, however,,retrieve only 95 files and had to carry ()ut our an~lysis all lhat number. Thcrcsults are tabulated and cxpressed in percentages.'Thc tablc bclow shows the proportion o( benign and malignant tumoursamong thc cases we studied.Table 1. The .I!l'oportiolls of the va.-ious.!y'~~()f tumours.Total 95---------------.-----------------... --------------------_._------------,) The finding of 25.3% of the cases to be malignant is an important point tonote. Benign tumours represcllled 64.2°,10 of the cases studied.'322

_..-,-~'__... .. .... ~_ .... ._._ ...__... •__...~_.. ••_-. ._._ _._.. •• • _ .._.,_... ~__ ....- o.-••__.. ,~ • .... _. ~ -- _"~- ~- --,,,-.._..,,••__•__- ..... _k..__ .,. _._-

~._-_ ....._.._..-........-...__.._.__.._..-.._.~. ....__J'~, I)1£_1. rI' It ~__rc!!!J.i() 11SIili~.J!!~t'" ~~J}...nl~ r iJ}~ll!U.!J.h£Jyl!.~_C)f _( 1.111~ () \1 r{Ji~)'V .~!}"-'-r'~;'~~iiy _.---... ·--------.·-------·Ik-~ig~;--- ..---..-··---' "-'-""- -·---------M;~lig;;;-;;t·-·,-~--·-- ·.. ---·---~·-lJnl{no\vl~··----- -';rot;~I--- ..,-_._-------------- ----_._--_.._------- -._--------_._"-..----- _ ....__._----- -........._-_..__.--- -.IT"cCJtlcn(~y 4X, IIJ·(~(]nellcy ex, Iire(llIcnl~Y (~)I. 0 49 8~.:.!!~ 3 5.08 7 11.86' 59.......---._...-.-.---.-,.,--,- ---_......_------------_. ---- .....--_..--...- ....--- .._-------_._---_P.. .-_- .__~__._____ _ ----.2. t lo2 9 64.29 5 35.7l 0 0 14--··3·~-3-~.~5-----··~·-·- "'-------"-----3----"'---" -·_-------25·------- .. -------·-----7'-------- -S8.33 --~ -------2 --'---l~67 ·-----12----"' ..----"._--..----------- .__•._-----_. "------- -.._-----_.__.. ~4. > 5 0 0 9 100 0 0 9~-------------- '_.._-,-_._--------------"5~ N(~~----- ------·-·0-------- -----------·0----·- -----0-·-----0--------1-----I06-- ~--I-_______.__--preciscd.. .. ... ...__.... .......__ ....._. "' .. ._.__._. .__.. ..._.... ..~l'otal!~! 64.21 24 25.26 10 10.53 95... . - ._...__c_..__-__.__IIAll tIle IUll1c)urs ill tile gral1cI Illultil)"r()tJS }JatieJlls "vere l11aligllullt. 011 tilec()lllrnry, 83.()S(Y() ()f' the tUllll)llrS ill the flltlJiJJarOLlS llat.ierlts \vcrc lJelligllunlike stated in the literature that Jlul1iparity is a reproductive risk factor forbreast carlcer. T~)o11 et al. fourld 111[lt l'll{)st l)[ tlleir cases of breast callcer weref11l11tiIJar()lIS Ullcl S() cC>llcluc]e~__, _....

_,_... - -_ __ __ ••••• • ' ~_~ ._,,_.__••__• _ __.~ .._ _ ~ .• _ .r" ..--••• • __ ~__ ._ __•__•• _ .__• ••__ • _ .. • ___... .. .. ~_____ .-.. • _..__.__.-.._---_.......- .._ ..... _ ...-_ ... _ ••_-_ ..........__ ~_-_.__••. .... _. .......-_.._ ••• _.__• .,--. ..__.. 4 .• ...__._..._. _ ....__._._.....__... ._. ~_... .. _-..- -- - - ,.- .. ~l,-~;i~;I-· .-. ---""'j--' '----'--'61-'- ---'-"-'(~4'~'2' i- "-·-·-·---·2~·i-···-- -.--. ·-i·5:-·l·i.~··" -----·---·l·()····------- ---i{l5~'- ----9·5--··3: f·~~·i):···· .~; ~-.~:._..-.... ..._,T--:-:=-_·· ... -.·~~:i·~~i··-.1·--- :.:~: --.__ j::f.§} -J--.--:-:=--- -- :-t~~6~- -j.j=--..IllCll

--.- - ..- ----.--.---.... - .. -.-.-""~--._,_._ oc..----•••- __ ~-...,.--._-- .. -----------_.._- ...---- ----.... _.-_._-_._----_.------.--,.,._,. - ..__._-_.•_._,- ---..._. -------_._--_.. - ...._---- ---_.._~.---__ .-- ,... .._••- ••__...._-."..... • _ •• ... ' •• ~.... ,. ....__•• .•_ .... _ k'·_ ••_.~_·· •k__._ ~_.•__ ..__... _~____._.....,••.. • .. .. ~.____.~.._~ ____:1." 11 IJIC ~. §~Y!!!l! t(!!!!§. ;1!!!I Cli!!i l~illl-j 11 ~1iU.gs ~!.!!t·) t. Y1!£~Q!~t (I.!!~) t I !~f.ll.()'\" (~)1Ifin (I i Jl g ....._._._~~~~~_~l __. . f-.. ---._~~ Ii I!~ ;~~~! ~ ~J n_~~~~'~~l_l '1'0(H IFrequency ~) I Frequency % Frequency %---._---_ .._- _... _-_.._------- ----_.. -_.._---_......-.. --_._-- ...-------------------------I. 56 ft?-:~l.1 17 20.99 8 9.88 81'l'lllllOllr2. Skin o o 2 100 o o 2change_.__•__.. _ ....._..~_ ... ••__.. a-..__••~.. ._. • ..._,._.__..._~ ....__.~ ~ ..__ • - -__---------3. Nipple 0 0 J .!.!)Q 0 0 3discharge4. Shape 5 55.56 2 22.22 2 22.22 9change_"'__._ • •• ._........... ....__ ••• _ •__• __• . __ w,.._.' ......~ __ .' ..__.• ........__•• _ .. ._-.. ..,._.... _ • "_-. __. _5. Not 0 0 () ()' 0 0 0precisedI----.------- ~... ~.-.--..--.-._. __.... ."' __. ._._. . . _..1__._ ___.. . -'rotal 61 64.21 24 25.26 10 10.536.Noduleill Hxilla• __ • • •__ _._.__• •••-.r.__•__ ~6.1. '~I cs 0 0 17 100 0 0 17---_ .._-_._,_...----_.- ._~--_.------~---~--6.2. No 61 !tQ.2(! 7 9.21 8 10.53 76G.3.Not 0 () 0 0 2 100 2prc.cisc(1'"l'o!nJ 61. 64.21 24 ~.5.26 10 In.53 95----_....__ .._...._--- -------- --'--'-"'- ----..._-- --_.._------ --_._---.._---- -._-AI11()llg tll(~ rJaticI1ls w}'}() C.()llSLlllec} f()r l)reast tlll'll()Ur, tllree (lllart.crs wereflaving l)Cllig;ll t.l1ll\()llrs. All 1.1lC 3 WilO \C()flSltltccl for al)110rlIlal rl.i[llJle

_-•.. _.---_._-~.- _.---.~._ ..-------_._---_.--_(~irCtllllstallCt.~S of

~- ...._-........--_._-.... --......-.._..._-.- ~ ..__._---.-'-.--1-~ '---'------. - .... - ...- ......---.------•••_~ .--.-~_....._._. __ ....._ ••__..__._. ._..- • •••_. ......_. • -.. ..0-.._- -__ • __]j!!> I(~ Q. rl'l, cl!:~(ll! (~I!.£L0 J~).:.w~~'og~.c.~LCX~~!!l i 1!!~_(!.9 liS .!_~.SC(!o.!.!.tlU~l!,-iI!g_t!!~­!,i ~g1\()S i~-.Q..fJ.!! c _!!~!11 0 !!.[~_1 ~.91!!.!~.!!.~~)}.IC:xn IIIinntion 1teS1H)USC Ilcnign.... .. . l\1nJignun t .1Jn1{llo\vll0__-r~'I'C(ll1cncY (X) [frccltlcncy (X) Ifre(IUcncy-------.....-.----.------.- .------------ -.-----..-.-.-.-- ....-----------.----.- --~- _.~-- ,---t---I. 11reast IJolle 59 2-().7~ 20 ~3.33 8 80--_ .._------ ._..------------- --- ...- --._._--~ ----------_.- --------_. -_._------_.-lJltrasound Not dOlle 2 3.28 2 8.33 2 20...• __._._-.-------~ ...._- _.. _....._._---_._---- .._._-.._-,'- -_._---..._-.---..,---No 0 0 2 8.33 0Inenlion"rotHI !i!. !PO 24 !Q.Q. !Q IOl!-2'~·--·---·_· __··--·--·-·----·--· ·--·_·-I);·~~-_· --------i·2 ----·-···--i9~67 --··----··1·7--~ '-70.83·-"--2--·-20......__.. .. ,..._.~ . ... ~ ...-......__..-._._4_..__ ___.,._____ ~__ .._ ... - ._ ._..__.... .._.. --.rvlalHIlH)graphy Not dOIl(~ 49 80.33 . ,5 20.83 8 80, .. .~_-__ • ~_ ... ••__4 • .. _-.. - , •__• _No 0 0 2 8.33 0 011ICIl lion....--.-...----------.---.-- .--~--_._-_.---".------------..---_ - . .1-__ "__ ._._~_rrotaJ Q! 100 £1 I !QQ 10oBreast ultrasollnd examination was more ft~equently requested) in more than8()%) of the cases. Tvla111111()gralJ)lY \V,lS 11

.._"- •__._.. - .... ~ .... __ _. ..- ..--.... - .....--..~.... 4~.....__• , .•_~ , -.. •....6_ __ __.. ._._ _. ~.__~_~.__.. ._ ..-. ._..__ ." • ._ _.__ a4...--_.~~...-.--..---- ~ _.--._-_...-----..----••, .........._ ...,-...._.__•••,_,_ - ....._ .. ~. _.. - ------._.__.-...__._ .. ..__• .......__ ....-.... ._._~~..._;.__ .__ .. •••••__ ._ -. .____ _ .....-...(':)'tC)I'Unc.ttlre \~VHS C.()111111C)l11y I)Crf.'C)rJ11C:({ ns a, cliagrFJstic stcr1, '73 .'7'7(~/;J in t.Ilegr()Ur) (J(' lJcnigll tlll1}()llrS (\n(1 g·7.S(~I() irl tIle grol.l1) of 111nligl1arlt lUl11()11rs.()11e.ll l)i()(')s)' \vas less fl"C(lllen,tly clcJne (1I1tt ll() lrtlClJt \'Vas t..l()lle ill all tile casesCl J,lCl' )'ze.cl.'I'rt'atnlcnt lll"uign IVlalignant' lJnl{IlO\VIl 'J'otaloption l('J·cerl rel)()rlccl in tl'le lit.eralllrc (2.),J\ 11 tile 1.UJll()UrS ill ()ur )Jatiellts agccl nlJ()vc 50 )'cars \"/ere 111ali[!,11allt. It isk11()\,V n i11 {{1e IjleratII re that. the 111 aj (Jri t)1 ()r Lrrc ~ \Stiesi (J J1sit1 1)0 Stille 11 (J I)ausnII)('\tie11tS II re 111aIi1~ 11 ~,llll (5). ()II r fi 11 (I,tl g~S \VCTe si IIIiI Cl r"1~ venth() 1I !!J'1 trllll tjJ)nrity a11 cl (')rt)I()11[;C(1 Iact Cl tit] n ar~ ~; (\ i(,1 l() l)Cl)l'C)tc (~tivc,("")111 4 "indillg~ \\'£.'1"0 f.finlil"r t,) lh()~iU "Jr [)l.,ll et ul. thnt. (hc~i(,j fht.~t.()I·a if) OLIIcllvir()11111CI1tten(l t() l)C Cl risk (2, t 5). J\S S11()vVrl il'l tl1c rcslllt scclic)11, we329t

()l)servecl S()111C risI< f~let()rSt

• That more diagnostics equipment be put in place especially forOestrogen and progesterone rcceptor testing.131

1. J\.llclersCI'I .13(), Sllyyall It, Elliu 1\, et al. 13reast callcer 1[1 lill1ite(lreS()llfCeC()llntries: all ()ver"ie\v ()f t]lC 13rcast I-Ie[tltll Global Illitiative20()5 gtticlelincs: 13rcast .J~ 2()()() ]nll-r;el1; 12 Slll)l)l 1:83-15. [Ilul)Mecl]2.1>11ilil) J. [)isa.ia, \\!il1iUlll '"r. CreaSll1all. Clillical GYllccologicOncology 4 1h edition 1993 pages 467-517.3. r>a u I [). (~~l\ntl, Sllsa11 !'vI, J()]111S()11. Cllrrel1t. cl illical strat.egies.C]YI1CColc)gy arld Ol)sletrics 2()06 eclitic)ll 11ages 4·4-4·7.'l. Kirl< J, l3reJ1I1Rll I\tl, ll, 121clragcely K, et al. Outcorlles ofsllrgical anci.. ! \s(Jrl()grnIJ]lic nsseSSllleJlt ()[ breast rnasses ill '\VOll1en younger tlle!]l 30.rg. 2()()5 Set); 71 (9): 71 (j··9. [IlltlJIvled].8. S()tiri()u C~~, Wirclj)[lti 1), t.A)i S, ct al. GeJle eXl)rcssil)ll ])rofilillg illIJrcast cancer: lJl1licrstallcling t.ile JllOleClllar l)asis of Jlislol()giccll gr,lclcto i111IJrC)VC })reJgrl()sis. it lf1St. 2006 fiel) 15; 98(4):262-72.. [I)lll)Me(i].9. Al)dtil···I{as()()1 S, l(i(lsOll SIT, IJanicri r~, ct al. /\11 evalllatiol1 ofIll0]ecular l11arlatllol. 20()6 M-ar; 59(3): 289-97. [l>Llt)Mecl].] ().AJllCrsi r·, [lallsell Nl\1. '"rile 1)CI1Cfits ancllilTlit.atiollS ()f serlt.illcllyrr1l)ll11()d(~ l)it)I)SY. r '"rreal ()Jlti()11S Ollc()l. 2()O(i Mnr; 7(2): 1-41-51.r. rll.ll)Mccl].332

I 1. Vall l(~jl( M(~, IJetlrl()() [~ll, Nievvcg ()I2, et. al. UJtr,lSOll()gral)ll)' allclfirlC-11CCcllc nSI)irati()ll c),tc)lc)gy earl SjJare l)rcast catlCer l1alicl1tstll1l1cceSSar)' selltillcl 1)/]111111 l1()clc IJi()I)SY. j\1111 Sllrg Ollc()l. 2006 Jrul;13(1): 1·-2. [I>ul)Mec.I].12. [)llrry IYIJ. SCfl.ll11 tUlllllr Illarkers ill breast CaJICer: Are tllCY ()f clillicalVB llle? (~] ill C:l"lclll. 2006 Mflr; 52(3): 345-51. [Illlt)Me(I].13. V"rgns 1-11, Vnrgas t\'11)" Elclragecly K. et al. Ollt.COll1CS of clillical al1dstlrgical asseSSll1cnt ()f VvOll1Cl1 ",rill} })alll()l()gicalllil)])le (lisclla.rge. All1Sllrg. 2006 l~cl); r/2(2): 12 l l-8. [lllll)rvrcd].1L~.Sauter 12 .. 13reast CHllcer (letection LlSillg lrlUll1111,lry (lllctosCOI)Y. Fllttlre()llcOl. 2()()5 JLlIl; 1(3): 385-93.15. Doh AS, Ndzi J, Nasah HT. The p~lttern of gynaecological111aligl1HflCY at the lJl1iversity lIosI)ital ~cl1tre (Cl-flJ) Yaollllde,ICall1CrO()Il. Cerlt A fr J Meel 1988 Nc)v; 3 t l( 11 ):260-4.333

H. /\.NNF:X 11: 5tl -= N()t J)rccisc(J5 :=.: ().. • • • • • • • • .. • • • •• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • .. • • .. .. • • .. •• [ J.. ... 3.'5.IJse () f (~'()(~:I -.:':: Yes2 ~~ Nt)3 ::7.-: N()[j)rccisccl ['.1 4G. (la t iell t. () 1.1 111~'1'1 ::~ y cs2 ~ N()J :.:-:: N( J)rccisccf [ :1 5

7. H.ainhow clT(~('t in the past hisloi'Yt ::.:: Yes2:--:. N()3 ;.-: ~r()t 1~)t'(""'("l'('('~(J [ "1 6.. l ", , I .)., ••••••••••••••••••••••••••••••••••••••••••••••••••••••• .' •••••B. Jlis(OIT of Bn~nsf caIlCt~J' in the family1 =-=)'cs') - ~.T4. - !'()3 :::= !'~ol prccisecl r ]. 79. Conirihufi"c past his(or'yI == Y cs2 :::0;: N()3 =-= Not prcciscd [ ] 810. Breast ahl1orlllaJi(yJ ::::' ['UJll()r2 == Skin change3 :::.:: Ni JJIJle

3 == N()t I) tOecise(j r• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ••• [ ] •••• 1]I 3. l,J It I'as() till(I (I()11 C1 == Yt~S2 == NoJ =:: N()t )Jrcciscc! [ ] '1 214. Mn1111)1 ()gr~ll) Ily (I() IleI == Yes2 == N()3 =: N()t l)recisecl J to [ loo13J5. (~~yt()I)llllet IJ re ()()IIC1 == 'ITes2 == No3 == N()t J1recisccl oo[ ] ••••• ILl16. r '('rll('.tlt (1()11e1 == Yes2 == Ne)3 = Not preciscd ':' , I: ] 151'l. ()I)Cll J>i()I)SYI :~::Yes2 :":.:: N(.l3 == }\!()l})recisc

] ~). 'I \ren f niPI} ~ () ()ti(),I1 ~ ("ll)Sel'VCll\()ll2 ::-: Sllr!!)cry1 7"":-: (':hClll()therH)1Y'1 =::: J~ nd i() tJ lern11y5 === C:hCll)Ol"