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Objectives: We aimed to investigate the overall survival (OS) of young women with endometrial cancer (EC) in Bulgaria and the impact of histological type on survival., Material and methods: This is a population-wide retrospective study of patients with EC (≤ 40 years at diagnosis) registered at Bulgarian National Cancer Registry (BNCR) between 1993 and 2020. Patients were re-classified according to the 8th edition of the TNM classification., Results: In total, 30 597 patients were registered and histologically confirmed with malignant tumors of the uterine body. From that, 29 065 of them (95%) had ECs, and the rest had sarcomas. Around 1.64% of all malignant tumors of the uterine body are diagnosed in women under the age of 40. Most of them are diagnosed in the early stage. There was no significant difference in median OS for patients diagnosed before or after 2003. In recent years there was a slight improvement in survival and patients from the last cohort of this study had a 5-year survival rate of 92.5%. Patients with favorable pathology (T1, G1/2) had no lymph node involvement at the time of diagnosis and their 10-year survival rate was 94%., Conclusions: EC in young women is a rare disease. In most cases, patients are diagnosed in early stageT1, G1/2, N0 and their prognosis is excellent. However, the lack of improvement of OS of young patients with EC in the last three decades shows the need for treatment optimization., peer-reviewed

Establishing a prognostic model for endometrial cancer (EC), that individualizes risk and management plan per patient and disease characteristics.this is multicentre retrospective study conducted in 9 European gynaecologic cancer centres. Women with confirmed EC between January 2008 to December 2015 were included. Demographics, disease characteristics, management, and follow-up information were collected. Cancer-specific survival (CSS) and disease-free survival (DFS) at 3 and 5 years comprise the primary outcomes of the study. Machine learning algorithms were applied to patient and disease characteristics. Model I: pre-treatment model. Calculated probability was added to management variables (model II: treatment model), and the second calculated probability was added to perioperative and postoperative variables (model III).Out of 1,150 women, 1,144 were eligible for 3-year survival analysis and 860 for 5-year survival analysis. Model I, II, and III accuracies of prediction of 5-year CSS were 84.88%/85.47% (in train and test sets), 85.47%/84.88% and 87.35%/86.05%, respectively. Model I predicted 3-year CSS at an accuracy of 91.34%/87.02%. Accuracy of model I, II and III in predicting 5-year DFS were 74.63%/76.72%, 77.03%/76.72%, and 80.61%/77.78%, respectively.Endometrial Cancer Individualised Scoring System (ECISS) is a novel machine learning tool assessing patient-specific survival probability with high accuracy.

Detailed knowledge of the human anatomy is an integral part of every surgical procedure. The majority of surgery related complications are due to a failure to possess appropriate knowledge of human anatomy. However, surgeons pay less attention of the anatomy of the anterior abdominal wall. It is composed of nine abdominal layers, which are composed of fascias, muscles, nerves, and vessels. Many superficial and deep vessels and their anastomoses supply the anterior abdominal wall. Moreover, anatomical variations of these vessels are often presented. Intraoperative and postoperative complications associated with entry and closure of the anterior abdominal wall could compromise the best surgical procedure. Therefore, sound knowledge of the vascular anatomy of the anterior abdominal wall is fundamental and a prerequisite to having a favourable quality of patient care. The purpose of the present article is to describe and delineate the vascular anatomy and variations of the anterior abdominal wall and its application in abdominal surgery. Consequently, the most types of abdominal incisions and laparoscopic accesses will be discussed. Furthermore, the possibility of vessels injury related to different types of incisions and accesses will be outlined in detail. Morphological characteristics and distribution pattern of the vascular system of the anterior abdominal wall is illustrated by using figures either from open surgery, different types of imaging modalities or embalmed cadaveric dissections. Oblique skin incisions in the upper or lower abdomen such as McBurney, Chevron and Kocher are not the topic of the present article.

This article analyzes sixteen censuses of the Bulgarian population in the period from 1879 to 2010. This work provides information on the normative and bylaws regulating the organization and stages through which the population censuses pass during the considered periods. The article traces the migration processes from the end of the 19th century to the beginning of the 20th century in the Bulgarian state, as well as a number of historical events that had a serious impact on the structure of the population. Attention is paid to the waves of refugees observed in the 20s of the 20th century, as the latter brought enormous financial and economic consequences for Bulgaria. Data on birth rate, death rate and natural population growth are presented. The age composition and educational status of the enumerated population is studied, as well as the degree of urbanization during some of the enumerations of the Bulgarian population.

Enhanced Recovery After Surgery (ERAS) is a complex system of procedures that necessitates multidisciplinary patient care during the preoperative, intraoperative, and postoperative phases. Over the last two decades, the ERAS protocol, which was initially described in colorectal surgery, has gradually expanded to other surgical specialties. Gynecological surgery is no exception, whether for benign or malignant conditions. The ERAS program's primary objective is to overcome the pathophysiological processes associated with surgical stress and to facilitate the patient's rapid recovery, while minimizing complications, hospital stays, and costs. The objectives of minimally invasive surgical procedures largely overlap with the objectives of the ERAS program. We analyzed scientific data from studies examining the ERAS system's application in minimally invasive gynecological surgery (MIGS) and present them in this review. The central question is whether the ERAS protocol can provide additional benefits beyond those inherent in minimally invasive surgical procedures.

The article aims to reveal both the emergence and historical development of vaccination and its regulatory framework. The subject of study is the administrative and legal regime of vaccination in Bulgaria. The author examines cases from the case law concerning the vaccination process.

Hereditary cancer syndromes are defined as syndromes, where the genetics of cancer are the result of low penetrant polymorphisms or of a single gene disorder inherited in a mendelian fashion. During the last decade, compelling evidence has accumulated that approximately 5-10% of all cancers could be attributed to hereditary cancer syndromes. A tremendous progress has been made over the last decade in the evaluation and management of these syndromes. However, hereditary syndromes associated with gynecologic malignancies still present significant challenge for oncogynecologists. Oncogynecologists tend to pay more attention to staging, histological type and treatment options of gynecological cancers than thinking of inherited cancers and taking a detailed family history. Moreover, physicians should also be familiar with screening strategies in patients with inherited gynecological cancers. Lynch syndrome and hereditary breast-ovarian cancer syndrome are the most common and widely discussed syndromes in medical literature. The aim of the present review article is to delineate and emphasize the majority of hereditary gynecological cancer syndromes, even these, which are rarely reported in oncogynecology. The following inherited cancers are briefly discussed: Lynch syndrome; "site-specific" ovarian cancer and hereditary breast-ovarian cancer syndrome; Cowden syndrome; Li-Fraumeni syndrome; Peutz-Jeghers syndrome; ataxia-telangiectasia; DICER1- syndrome; gonadal dysgenesis; tuberous sclerosis; multiple endocrine neoplasia type I, II; hereditary small cell carcinoma of the ovary, hypercalcemic type and hereditary undifferentiated uterine sarcoma; hereditary diffuse gastric cancer and MUTYH-associated polyposis. Epidemiology, pathogenesis, diagnosis, pathology and screening of these syndromes are discussed. General treatment recommendations are beyond the scope of this review.

The Enhanced Recovery After Surgery (ERAS) system is a collection of preoperative, intraoperative, and early postoperative measures. The primary goal of gynecological surgery is a rapid and uneventful recovery from oncological and standard procedures, particularly in patients over the age of 65. The goal is to achieve comparable results to those obtained with minimally invasive procedures. Certain features of the ERAS system are similar to those of standard surgical procedures. These are the measures taken to prevent thromboembolism and to promote early postoperative mobility. Anesthesia and postoperative analgesia are critical components of achieving the ERAS system's objectives. The ERAS protocol requires multimodal non-opioid postoperative analgesia, infiltration of the surgical wound with a local anesthetic, and avoidance of opioid analgesics. We discuss current data on patient management according to the ERAS protocol for anesthesia and analgesia in order to minimize the body's stress reactions, promote early mobility, and reduce postoperative complications. ERAS protocol has gained popularity in recent years in a number of centers, primarily in the United States and Europe, due to its direct impact on hospital stay length, healthcare costs, and benefits for patients, their relatives, and caregivers. Keywords: ERAS protocol; multimodal opioid-sparing analgesia; local infiltration anesthesia.

The presence of multiple primary tumors is a rare condition. They are classified as synchronous and metachronous tumors. The incidence of synchronous tumors is 0.7-1.8 percent. In gynecological practice they are extremely rare events with the most common combination being simultaneously developing uterine and ovarian carcinomas. The likelihood of metastatic disease should be ruled out in these cases, and for which criteria have been established. Most often, the manifestations of the disease are more characteristic of endometrial cancer. Staging accuracy and proper diagnosis of tumor processes is essential for the treatment and outcome of these patients. Usually, the diseases are at an early stage and have a good prognosis. The mean age of diagnosed patients is 48.4 years, mostly women who have not given birth, and with obesity. We present a case of a 37-year-old patient diagnosed with synchronous endometrial and ovarian cancer, at which both malignant processes failed to fully meet the criteria.

The present review introduces the aetiology and classification o f c ervical p recancers. T he p rinciples o f diagnosis based on colposcopy are reviewed. The indications for colposcopy and targeted biopsy are steps in the diagnostic process of cervical precancers. Prophylaxis of these diseases prevents cervical cancer as high-grade precancerous lesions represent a direct precursor to cervical cancer. The basics of primary and secondary prevention, the types of screening, and the behaviour of the already-alerted patients after different screenings are presented.

Background and Objectives: The tumor microenvironment (TME) plays a major role in neoplastic development. Various types of cells can be found in the TME. These cells can be classified into two groups, immunosuppressive and immunostimulatory types, depending on the function they perform in the antitumor immune response (IR). By interacting both with each other and with tumor cells, different immune mechanisms are activated or inhibited, which can suppress or promote the development and progression of cervical cancer (CC). Our aim was to investigate some of the main components of the cellular immune response in TME—tumor-infiltrating cytotoxic T cells (Tc, CD8+) and tumor-associated macrophages (TAMs, CD68+)—in patients with CC. Materials and Methods: We analyzed 72 paraffin-embedded tumor tissues of patients diagnosed and treated at Medical University Pleven, Bulgaria. Patients were classified according to the 2018 FIGO (International Federation of Gynaecology and Obstetrics) classification. From each patient, we selected one histological slide with hematoxylin eosin staining. In a microscopic evaluation, CD8+ T lymphocytes and CD68+-positive macrophages were counted in the tumor and stroma of five randomly selected fields at ×40 magnification (HPF). We analyzed the relationship between intratumoral and stromal CD8 and CD68 expression and FIGO stage and N status. Results: There was no significant association between the expression levels of intratumoral and stromal CD68+ cells in the different FIGO stages and according to the lymph nodes’ involvement. For CD8+ cells, the association of stromal infiltration was also not found, but T intratumor infiltration was associated with a higher FIGO stage, despite the fact that the results did not reach significance (p = 0.063, Fisher test). Intratumoral CD8+ cells were significantly associated with positive N status, (p = 0.035). Discussion: The separation of tumor-infiltrating cytotoxic T cells and tumor-associated macrophages into intratumoral and stromal is inconsequential. In our study, the level of infiltration of CD68+ cells in tumors and stromata was not significantly associated with tumor progression or lymph node involvement. The results were different for CD8+ cells, in which levels of infiltration were associated with lymph nodes’ statuses. Conclusions: The separate evaluation of CD68+ immune cells in the TME as intratumoral and stromal is not beneficial for defining prognoses, since the presence of these cells is not associated with the patient’s stage. In our study, the presence of CD8+ cells was significantly associated with lymph node metastases. The prognostic value of the obtained results can be enriched with an additional study of the lymphocyte phenotype, including B and other subtypes of T lymphocytes, NK cells, as well as molecules involved in the immune response, such as HLA subtypes.

Pseudomyxoma peritonei (PMP) is a rare and uncommon condition, characterized by the presence of mucinous ascites in the abdominal cavity. The most common cause of PMP is mucinous adenocarcinoma of the appendix, followed by neoplasms of the ovary, endocervix, fallopian tube, alimentary organs, urachus, urinary bladder, lung, mucinous cyst of the spleen, and breast. Herein, we report a case of a 64-year-old postmenopausal woman (gravida 2, para 2) who presented at the department of gynecology with a short history of nausea and abdominal distention. Abdominal and vaginal ultrasonography showed a large amount of free fluid in the pelvis with hyperechoic echogenicity and right pelvic tumor with mixed echogenicity. Computed tomography demonstrated the presence of a heterogeneous, hypodense mass, without contrast enhancement, located on the right side of the pelvis, near the right ovary. Laparotomy was performed. Revision of the abdominal cavity revealed a large amount of yellow gelatinous mucinous ascites – approximately 1.5 l. A tumor (6 x 7 cm in diameter), arising from the appendix and located in the pouch of Douglas near the right ovary, was observed. Histopathology examination revealed poorly differentiated mucinous appendiceal adenocarcinoma, comprising up to 50% signet ring cells. Gastrointestinal tumors such as appendiceal neoplasms combined with PMP may mimic ovarian carcinomas. Computed tomography, abdominal/vaginal ultrasonography and tumor marker levels (carcino-embryonic antigen, carbohydrate antigen 19.9, carbohydrate antigen Ca-125) may establish the diagnosis. A differential diagnosis with appendiceal tumors should be considered for patients with right pelvic masses.

Introduction Endometrial cancer (EC) is the sixth most common malignancy in women worldwide; in developed countries this oncological entity climbs to fourth place. In 2012 worldwide 319 600 new cases were registered and about 1/3 of those were diagnosed in Europe, i.e. more than 100 000 cases. Statistics in Bulgaria show an increase in the incidence; the National Cancer Registry reported an incidence rate of 8.6% for 2013, with 1293 new cases; about 300 women die because of this diagnosis every year. Clear-cell endometrial carcinoma (EC) is relatively rare, in 1–6% of cases, with significantly shorter survival rates even for early stages (I and II), compared to the other histological subtypes. Case report A 62-year-old patient was subjected to surgery for clear-cell endometrial carcinoma, stage pT1N0M0, FIGO stage IA. Despite radical surgical treatment as per Bulgarian oncological standards – total hysterectomy with bilateral adnexectomy and pelvic lymph node dissection with postoperative radiotherapy – there was a recurrence in a the paraaortic lymph node 15 months later. A second surgical intervention with radical resection of the parailiac metastatic lymph nodes on the left was done with subsequent pseudo-adjuvant platinum-based chemotherapy, and no further relapse has occurred 36 months later. Conclusions Clear-cell EC is an aggressive disease with worse prognosis than the endometroid subtype. Therefore, comprehensive surgery and surgical staging should be performed, including pelvic and paraaortic lymph node dissection, regardless of stage.

Introduction. In 2018, the number of newly diagnosed breast carcinomas in the 28 countries of the European Union was 404 920, with an estimated annual incidence of 144.9/100 000. Figures have increased since the introduction of mammography screening and continue to rise with population aging. Mammograms may convey clinically occult breast cancer, which is associated in some cases with the presence of clustered microcalcifications. Case presentation. We present the case of a 64-year-old patient with multifocal invasive ductal left breast cancer and lobular carcinoma in situ, diagnosed after biopsy of a mammogram-marked area with clustered microcalcifications. The patient underwent subsequent radical surgical treatment. Conclusions. Clustered microcalcifications on mammograms may indicate clinically occult breast cancer. These lesions cause clinical and diagnostic difficulties due to the inability of ultrasound visualisation and the option to perform punch biopsy, as recommended by European Society for Medical Oncology. Excision biopsy by mammography-guided wire marking and pathological-anatomical examination of the entire resectate can detect tumour heterogeneity, which is important for the subsequent therapeutic strategy and prognosis of the disease. En 2018, le nombre de cancers du sein nouvellement diagnostiqués dans les 28 pays de l’Union européenne était de 404 920, avec une incidence annuelle estimée à 144,9/ 100 000. Les chiffres ont augmenté depuis l’introduction du dépistage par mammographie et continuent d’augmenter avec le vieillissement de la population. Les mammographies peuvent signaler un cancer du sein cliniquement occulte, associé dans certains cas à la présence de microcalcifications en grappes. Présentation du cas. Nous présentons le cas d’une patiente de 64 ans atteinte d’un cancer du sein gauche canalaire invasif multifocal et d’un carcinome lobulaire diagnostiqué in situ après biopsie d’une zone marquée par mammographie avec des microcalcifications en grappes. Le patient a subi un traitement chirurgical radical ultérieur. Conclusion. Les microcalcifications groupées sur les mammographies peuvent indiquer un cancer du sein cliniquement occulte. Ces lésions entraînent des difficultés cliniques et diagnostiques en raison de l’impossibilité de visualiser par les ultrasons et de l’option d’effectuer une biopsie par ponction selon la recommandation de la Société Européenne d’Oncologie Médicale. La biopsie d’excision par marquage au fil guidé par mammographie et l’examen anatomo-pathologique de la zone réséquée peuvent détecter une hétérogénéité tumorale qui est importante pour la stratégie thérapeutique et le pronostic de la maladie.

Introduction Prevotella bacilli are prevalent in the body as members of the normal flora and in some cases they can be involved in infections throughout the body. Prevotella bivia is a member of a nonpigment group found in the resident flora of the female genital tract and it is occasionally seen in the oral cavity. Case report We describe the very rare case of a 39-year-old woman with fulminant generalized peritonitis secondary to purulent salpingitis caused by Prevotella bivia. Discussion In most cases described in the literature, Prevotella bivia was mixed with aerobes and caused bacterial vaginosis and pelvic inflammatory disease, whereas in our case study Prevotella bivia was the only microbe that was isolated. The infection was fulminant and caused generalized peritonitis. Rapid and systemic infections typically occur in immunocompromised hosts, however our patient was in good health condition and immunocompetent. Conclusions Prevotella bivia may cause rapid and systemic infections, even in immunocompetent hosts. Multidisciplinary team management is mandatory in order to estimate the optimal treatment regimen.

Vulvar leukoplakia is not a histological diagnosis and involves several diseases. Most commonly, these are vulvar lichen sclerosus and squamous cell hyperplasia of the vulva. These two conditions have similar aetiology, clinical presentation and treatment but different histopathological changes. They both lead to significant impairment of quality of life, risk of malignancy, as well as recurrence after treatment. Treatment of these conditions includes topical corticosteroids as a first-line therapy, but they have their side effects and not all patients are receptive to this therapy. This requires the use of alternative therapeutic options such as topical calcineurin inhibitors, topical and systemic retinoids, other steroid creams, various destructive techniques and, as a last resort, surgical removal of affected tissues. Surgical treatment should be avoided, despite the malignant potential, because of recurrence risk in both diseases New therapeutic approaches are coming into effect in gynaecological practice due to potential risks of the above-mentioned methods. Platelet-rich plasma therapy, ablative and non-ablative laser treatment, and new topical medicines, are some of the new options applied to improve the efficacy of treatment avoiding the side effects of conventional medications. A number of them are still in their initial phase of application and time will tell their effectiveness.

Introduction The systemic lupus erythematosus (SLE) is a comparatively rare chronic autoimmune disease in women of reproductive age, the pathogenesis and therapy of which also conditions the increased risk of development of malignant diseases. Case report We present a clinical case of a 38-year-old female patient with lupus and stage 1B1 adenocarcinoma of uterine cervix, in which robotic radical hysterectomy with pelvic lymph node dissection has been successfully performed. The strict primary and secondary prophylaxis for pathological changes of uterine cervix are of essential significance for patients with lupus. Conclusions SLE is a chronic autoimmune disease, which is frequently treated with immunosuppressors, and affects most often women in reproductive age. The combination of these conditions is associated with higher risk of infecting with HPV and occurrence of pre-cancer and cancer of uterine cervix. Based on these reasons women with SLE must undergo strict screening follow-up and vaccination against high-risk strains of HPV. In the cases of cancer of uterine cervix diagnosed in initial stage, the striving towards minimal traumatism and better quality of life of patient - and, at the same time, towards achievement of optimal radicality - directs to the choice of minimally invasive operative method such as the robotic surgery.

Uterine fibroids are the most common benign gynecological neoplasms, with a higher prevalence in women aged between 30 and 50 years old. Fibroids may be asymptomatic, but in some cases, they can affect seriously the quality of life of the patients. In some cases, we can recommend expectant management for asymptomatic patients. Management depends on the size and location of fibroids, the age of the patient, symptoms, desire for future childbearing and the experience of the gynecologist. Medical therapy includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs (reduce heavy menstrual bleeding). Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are used mostly preoperatively. Surgical treatment includes hysterectomy, myomectomy – invasive and minimally invasive. Non-surgical management include uterine artery embolization, and focused ultrasound surgery.This review aims to present the role of High-Intensity Focused Ultrasound in the treatment of uterine fibroids.

Gestational trophoblastic disease (GTD) covers a range of proliferative disorders from non-neoplastic hydatid moles to malignant neoplastic conditions such as choriocarcinoma. The incidence of these diseases is low and often challenging to diagnose. Placental site trophoblastic tumour (PSTT) is the rarest form of GTD, accounting for up to 3% of all cases. We present a case of a 35-year-old patient diagnosed with PSTT mimicking an intramural pregnancy. Placental site trophoblastic tumour occurred after pregnancy, which ended as a blighted ovum. β-hCG was not very high, and the patient had no complaints. The diagnosis was made after resection of formation which was accepted for intramural pregnancy. To our knowledge, this is the first such case described in the literature. A hysterectomy performed later confirmed the absence of a residual tumour after conservative intervention. The lack of distant metastases, confirmed by positron emission tomography-computed tomography scan, allowed for only hysterectomy with bilateral salpingo-oophorectomy to be performed. The patient was classified as low risk according to the World Health Organization (WHO) scoring system. Placental site trophoblastic tumour is a rare malignant tumour (despite its WHO coding) from the group of GTDs. It is not presented with a classic clinical picture, and its clinical diagnosis is challenging. However, clinicians should consider it in the case of unclear events after any type of pregnancy.

Theresienöl is a 100 % natural product representing a mixture of animal and vegetable raw materials from Tyrol. Its exact recipe has been preserved untouched and in deep secret for more than six centuries yet, and has been passed down from generation to generation. Six patients were included in this case series one patient with malignant melanoma of the skin after re-excision with subsequent non-free skin surgical plastic, two patients with III degree skin burning and three patients with infected wound successfully treated with Theresienöl. All of them - before the application of Theresienöl - were treated with different operative methods. The treatment of scars from operative interventions with Theresienöl is very effective. That is why it must start directly after the operative intervention. The therapeutic effect of Theresienöl for postoperative scars is commensurable with and even better than the one of all applied until now local medicines, which makes it an agent of choice in those cases. Theresienöl represents a good alternative to the free skin surgical plastic for small burns of III degree. The local treatment of infected wounds with Theresienoil is more effective and economically sound than the treatment with all the rest types of dressings. The effects from the treatment of different surgical diseases with Theresienöl occur very rapidly, while there is a very good response to local hematomas, pain, and itchiness by the medicine, and there are no side effects from its administration.

Eastern Europe continues to have the highest rates of cancer of the uterine cervix (CUC) and human papillomavirus (HPV) infection in Europe. Aim: The aim of this study was to investigate CUC trends in Bulgaria in the context of a lack of a population-based screening program and a demographic crisis. Methodology: This was a retrospective study of 7861 CUC patients who were registered in the Bulgarian National Cancer Registry (BNCR) between 2013 and 2020 and followed up with until March 2022. We used descriptive statistics and modeling to assess temporal trends in new CUC incidence rates and identify factors associated with survival. Results: Bulgaria’s population has decreased by 11.5% between 2011 and 2021. The CUC incidence rate decreased from 29.5/100,000 in 2013 to 23.2/100,000 in 2020 but remains very high. The proportion of patients diagnosed in earlier stages of CUC has decreased over time. Up to 19% of patients with CUC in Bulgaria are diagnosed between the age of 35 and 44 years. The median survival was 101.5 months, with some improvement in later years (adjusted HR = 0.83 for 2017–2020). Conclusions: In countries with well-established population-based screening, CUC is nowadays considered a rare disease. However, it is not considered rare in Bulgaria. Population-based screening starting at an earlier age is the fastest way to improve outcomes.

Endometriosis is common in premenopausal women and affects about 10% of women of reproductive age. It is a benign condition but demonstrates malignant behaviour with recurrences and metastases. Its tendency to increase the risk of specific subtypes of ovarian cancer is being discussed, because they exhibit specific clinical features that distinguish them from classical ovarian cancer. Malignant transformation of endometriosis goes through its transition to atypical endometriosis. Although endometriosis-associated ovarian carcinomas have a good prognosis, adequate follow-up and monitoring after treatment of endometriosis are recommended.

Introduction Radiotherapy (RT) is a widely used treatment modality of malignant tumours of the uterine cervix and body. There are different techniques to deliver RT to the tumour lesions, including external beam radiation and brachytherapy. All international guidelines recommend RT as treatment modality for many stages of uterine cervical and body cancers because it improves a number of oncological outcomes, such as disease-free and overall survival. However, it may also lead to a number of complications, which can be roughly divided into early or late, depending on the time of their manifestation. The most frequent RT-induced early complications involve the skin and the soft subcutaneous tissues. They typically present as inflammatory conditions of all abdominal wall layers: dermatitis, cellulitis, and necroses of subcutaneous fatty tissue, muscles, or fasciae. Case report This paper presents a case report of a 38-year-old woman diagnosed with endometrial cancer (EC). She was initially treated with open abdominal surgery, and subsequently the treatment was continued with external beam adjuvant RT. Discussion While RT was ongoing, a necrosis of the anterior abdominal wall in the surgical scar developed. It manifested at the end of the RT treatment and is thus regarded as an early complication of the RT for EC. It was successfully managed with surgery, and there was no compromise in the treatment of the oncological condition. Conclusions RT-induced necrosis of the surgical scar of the anterior abdominal wall is a very rare complication. Surgical treatment is the main method of treatment of this condition.

Introduction: Cervical cancer is the fourth most prevalent malignancy and the fourth leading cause of cancer-related death in women around the world. Histologically, squamous cell carcinoma (SCC) is the most common form of cervical cancer. SCC has several subtypes, and one of the rarest is papillary squamotransitional cell carcinoma (PSCC). In general, PSCC is believed to have a similar course and prognosis to typical SCC, with a high risk of late metastasis and recurrence. Case report: We discuss the case of a 45-year-old patient diagnosed with PSCC who was admitted to our department in December 2021. The clinical manifestations were pelvic discomfort and lymphadenopathy throughout the body. On admission, all laboratory values, with the exception of C-Reactive Protein (CRP) at 22.35 mg/L and hemoglobin (HGB) at 87.0 g/L, were normal. The clinical and ultrasound examination revealed a painful formation with indistinct borders in the right portion of the small pelvis. Following dilation and curettage, a Tru-Cut biopsy of the inguinal lymph nodes was performed. The investigation histologically indicated PSCC. MRI of the small pelvis showed an endophytic tumor in the cervix with dimensions of 35/26 mm and provided data for bilateral parametrial infiltration; a hetero-intensive tumor originating from the right ovary and involving small intestinal loops measuring 90/58 mm; and generalized lymphadenopathy and peritoneal metastases in the pouch of Douglass. The FIGO classification for the tumor was IVB. The patient was subsequently referred for chemotherapy by the tumor board’s decision. Discussion: Despite the generally good prognosis of SCC, PSCC is a rare and aggressive subtype. It is usually diagnosed at an advanced stage and has a poor prognosis. Conclusions: PSCC is a rare subtype of SCC, and its diagnosis and treatment are challenging.

Background and Objectives: Cancer patients are at increased short- and long-term risk of cardiac toxicity and mortality. It is well-known that cardiac morbidity and mortality follows a seasonal pattern. Here we address the question of whether heart disease-related fatalities among cancer patients also follow a seasonal pattern. Materials and Methods: We performed a retrospective analysis of seasonality of deaths due to heart diseases (n = 503,243) in patients with newly diagnosed cancer reported during the period from 1975 to 2016 in the US’s largest cancer registry—the Surveillance, Epidemiology, and End Results (SEER) database. Seasonality was assessed through a classical cosinor model assuming a single annual peak. Results: We identified a significant seasonal peak in the first half of November. A peak with identical features was for all subgroups of patients defined based on demographic characteristics. This was also the case when analysis was performed on subgroups defined by the type of malignancy. Only patients with acute leukemias, pancreatic cancer and nervous system malignancies did not have a seasonal pattern in heart disease-related fatalities. Conclusion: the rate of heart disease-related fatalities after cancer diagnosis follows a seasonal pattern similar to that observed for the general population, albeit with an earlier peak in November. This suggests that close monitoring of the cardiovascular system in cancer survivors must be particularly active from late autumn and during the entire winter period.

We review the current research literature on treatment behaviour for neoplasms of the female genital tract during pregnancy. Guidelines for clinical management of cervical cancer, ovarian tumours, and vulvar cancer are presented both regarding gynaecological oncologic treatment and obstetrics. Cervical cancer is the most common malignant tumour of the female genitalia during pregnancy due to the high incidence of this neoplasm in developing countries, including Bulgaria, on the one hand, and on the other, it affects women of reproductive age. Treatment algorithms depending on various factors – gestational age, stage of the disease, tumour lesion size, and presence of pelvic lymph node metastases, are presented. Ovarian tumours are classified into benign, borderline malignant, and malignant tumours. The latter, in turn, are divided into early and advanced stages, as well as epithelial and non-epithelial tumours, which can be detected at different stages of pregnancy.

Pregnancy-associated malignant diseases introduce multiple dilemmas to the multidisciplinary boards, related to both the oncological treatment as well as to obstetrical management. The most frequent oncological diseases diagnosed during pregnancy are breast cancer, oncohematological conditions, uterine cervix cancer and skin cancers. There are different clinical scenarios: interruption of the pregnancy and further use of the most appropriate oncological strategy; it is also possible to postpone the oncological treatment for the postpartum period with a watch-and-wait strategy until the foetus is mature and the delivery is planned. The third scenario includes concurrent treatment of both conditions: use of chemotherapy, radiotherapy and surgery during an ongoing pregnancy. Choosing among these scenarios is considering many factors, including type and stage of the malignant tumour, pregnancy term, desire and informed decision of the pregnant woman to keep or interrupt the pregnancy. The current review is focused on the basic principles of the oncological modalities (surgery, chemotherapy and radiotherapy) during pregnancy as well as their influence over the pregnant woman and the foetus, over the obstetrical management and the timing and mode of delivery, delivery anaesthesia, lactation and breastfeeding from the point of view of the evidence-based medicine.

The retroperitoneum in the pelvis includes all pelvic spaces (Retzius’, vesicocervical/vesicovaginal, rectovaginal, presacral, pararectal and paravesical) and vital structures such as nerves, vessels, lymph nodes and ureters. Eradication of endometriosis, myomectomy of intraligamentary myoma, urogynecological reconstructive and oncological exenterative surgery require wider anatomical knowledge in the retroperitoneum. Generally, the retroperitoneal space is used for plane of dissection when the peritoneal cavity is obliterated. In the medical literature, there are few articles reporting the important relationship between retroperitoneal accesses, anatomical landmarks and anatomical variations in surgery. In the present article, lateral transperitoneal accesses to the pelvic retroperitoneum by open surgery are discussed. Furthermore, anatomical landmarks and anatomical variations encountered during retroperitoneal dissection are analyzed. Providing comprehensive knowledge of lateral transperitoneal accesses to the pelvic retroperitoneum will decrease patient’s morbidity and mortality. The recognition of retroperitoneal anatomical landmarks and anatomical variations will give surgeons more confidence. They should be familiar with anatomical variations, which are likely to occur during retroperitoneal accesses and dissection.

Introduction. Skin burns are one of the most common traumatic injuries in human society. Most of them are small in area and not life-threatening, due to which people hardly look for specialized medical care for their treatment. This is not the case with large burns, which even of a low grade may result in serious complications and even death. According to the injury depth the burns are divided into 1st, 2nd, 3rd and 4th degree, while the most frequently used method to define their area relative to the total body surface is that of the nines. The treatment of burns is a difficult and slow process and is directly depending on their depth, area and injuring agent. Surgical and non-surgical method are used, their goal being the following: pain reduction, prevention of infection, removal of avital tissues, preventing the formation of coarse scars, keloids and contractures of the joints or if the patient has them, they to be as minimal as possible and finally overcoming the consequences. Cases presentation. We present here two clinical cases of 3rd degree limited burns, initially treated with necrectomy and antiseptic silver dressings, and subsequently alternatively with Тheresienöl. Conclusions. Тheresienöl is a good alternative to the free skin graft plastics, when it refers to 3rd degree, small size burns.

Lymphoepithelioma-like breast carcinoma (LELC) is a rare type of malignant breast tumor that is not included in the current edition of the World Health Organization (WHO) classification of breast tumors. Currently, there are no clearly defined therapeutic strategies, and the general information on breast LELC is based on sporadic clinical cases described in the medical literature. We present a clinical case that describes a 49-year-old woman with a tumor formation in the right breast, histologically verified as LELC, together with a non-palpable, synchronous high-grade invasive ductal carcinoma and ductal carcinoma in situ Grade 2 (DCIS G2) in a different quadrant of the same breast. To our knowledge, this is the first case described in the literature that combines a LELC with a synchronous carcinoma in the same breast.

Gynecological cancers (GCs) are currently among the major threats to female health. Moreover, there are different histologic subtypes of these cancers, which are defined as ‘rare’ due to an annual incidence of

The chronic pain syndrome is a serious post-operative complication. In our practice we have discovered a certain percent of neuralgia of the pudendal nerve in vaginal surgery – more precisely in Bartholin’s cyst removal. As a highly efficient countermeasure we propose a nerve block of the pudendal nerve. We have performed a retrospective study of patients who underwent a Bartholin’s cyst removal in the span of 1 year from January 1st 2019 to December 31st 2019. All of the patients included are diagnosed with chronic pain in the area innervated from the pudendal nerve. In all of the patients a pudendal nerve block with local anesthetic was performed under the guidance of ultrasound. A total of 11 patients were included in the study. There was a time interval between the Bartholin’s cyst removal surgery and the performance of the nerve block. All patients expressed moderate pain before the procedure. In only 1 case a repeat of the nerve block was imposed. There were no short- or long-term complications of any kind. The patients have been followed-up in the duration of 1 year and 100% has been reported. Accurate and precise pain assessment is vital of the diagnosing and subsequent treatment of the chronic pain syndrome. There are many ways of treating the syndrome both conventional (non-steroidal anti-inflammatory drugs, opioids, topical analgesics and adjuvant analgesics) and unconventional. Chronic pain syndrome is an important multilayered problem that requires personal approach. The nerve block of the pudendal nerve is a highly efficient method of coping with that disease.

Introduction The term vulvar leukoplakia encompasses a variety of non-inflammatory diseases that lead to skin discoloration of the external genitalia and white colouration. Most commonly, these are vulvar lichen sclerosus (VLS) and squamous cell hyperplasia of the vulva (SCHV). They have similar aetiology, clinical presentation, and treatment but different anatomical pathology. Aim of the study The study aims to determine the effect of Theresienol herbal oil treatment in patients with clinically proven diagnosis of VLS and SCHV. Material and methods This prospective study includes 17 patients with a diagnosis of VLS and SCHV, who underwent a 3-month treatment course with Theresienol herbal oil. All patients were followed up for 1 year after therapy initiation, and the effect of treatment was reported using a visual analogue scale (VAS) for genital itching. Results The median age of patients enrolled was 60.6 years (range 42-74); 2 patients dropped out due to failure to attend follow-up visits. The mean score of the VAS taken at the beginning of treatment was 1.65 (0-5); at the 3rd month the mean score was 9 (8-10) and it remained similar at the 12th month - 8.67 (7-10). Conclusions Theresienol herbal oil treatment of vulvar leukoplakia is effective and safe, but studies should be continued.

IntroductionWarty carcinoma (WC) of the uterine cervix is a rare subtype of squamous-cell carcinoma (SCC), and its frequency, clinical behaviour, and aetiology are obscure. It originates from condylomas, and a viral carcinogenesis seems logical.Material and methodsRetrospective analysis was performed of all cervical carcinomas (CC), diagnosed at a single institution for a 10-year period. Analysed patients had stage I carcinoma. Patients with WC were identified, and their tumour samples were tested for high-risk HPV (hr-HPV) and EBV, using PCR and ISH. Clinical characteristics and WC rates across all stage I CC patients were assessed. All patients had minimum 3-year follow-up, and overall survival (OS) and 5-year survival rates were calculated.ResultsWC comprised 2.2% of all stage I CC (n = 630). The mean age of the patients was 48 years (range: 29–72). The primary tumour size was 2 cm in 4 (28.6%) patients, 2–4 cm in 2 (14.3%) patients, and 4 cm in 8 (57.1%) patients. Lymph node metastasis was found in 1 (7.1%) patient. EBV or hr-HPV were detected in 2 (18.2%) patients using ISH, with no coinfection reported. Hr-HPV was detected in 2 (18.2%) patients; EBV in 4 (36.4%) cases, and in 2 of them (18.2%) there was a co-infection. Thirteen patients had a follow-up of ≥ 5 years and their 5-year OS was 100%.ConclusionsWC is a rare subtype of SCC with good prognosis, regardless of viral status. In contrast to SCC, its aetiology is not related to hr-HPV. The role of EBV remains unclear and cannot currently be denied.

The surgical site infection is a dangerous complication, occurring in surgical patients, which results in aggravation of the postoperative period. It occurs within 30 days from the surgical intervention at the surgical site or the same body area. The most common reason is bacterial contamination from the skin, genital or digestive systems, its main cause being S. aureus. This type of infection is classified as: superficial – affecting the skin and hypoderm; deep – when affecting the fascia and the muscles and organ-based – when affecting body cavities and organs therein. The signs for superficial infection of the surgical site are: presence of necrotic edges of the surgical wound, suppuration running out of it, reddening, swelling, pain and warming of the site. In the treatment of surgical site superficial infections, the following methods are being used: systemic antibiotic therapy, taking out the skin stitches, pus drainage, surgical and non-surgical necrotomy, local vacuum therapy, local application of antiseptic dressings, hyper-bar oxygenation, local administration of products, facilitating granulation and epithelization. We present here two clinical cases of alternative treatment with Theresienöl of surgical site superficial infection.

One of the basic stages in the treatment of skin malignant melanoma is performing re-excision of the affected site, which should be implemented within 4-6 weeks following the biopsy-based diagnosis. Normally the surgical incision is within the margins of 2 cm in all directions. An exception from this rule is allowed in thin lesions and such located on face area, where the margins are around 1-1.5 cm. Most of the cases after re-excision need closure of the skin defects using different various of plastic surgical recovery, which on its hand results in formation of cicatrices, varying is shape, size and location. Nowadays more and more attention is paid to local, conservative treatment of scars of different nature, the key alternatives for it being: silicon gels and dressings, pressure garments, transforming growth factor (TGF-β3) and UV-protection creams, factor >50. All of them influence upon different mechanisms in the formation of cicatrices with the sole objective the latter to be as tiny and invisible as possible. Herein we present a clinical case of alternative local treatment with Theresienöl of a scar on the left side of the face of an 82-years old woman, due to surgical treatment of nodular malignant skin melanoma, located temporally in the left.

Potter’s sequence is a rare and fatal disease. There are four types of Potter’s Syndrome. Neonates with classical Potter’s sequence are with oligohydramnios and bilateral renal agenesis. They die shortly after birth because of severe respiratory distress due to pulmonary hypoplasia. Babies have typical physical features — Potter’s face, absence of kidneys and skeletal malformations. We report a fatal case of Potter’s sequence with a typical physical appearance. We performed an autopsy after the delivery.

Introduction Cervical cancer ranks as the fourth leading cause of female cancer in Bulgaria. The objective of the study was to describe the current burden of cervical cancer in Bulgaria for a one-year period and prevention options. Methods In this retrospective epidemiological study, online database from National Statistical Institute-Sofia, National Center of Public Health and Analyses-Sofia, National Center of Infectious and Parasitic Diseases-Sofia for one year were analyzed. Annual data were presented in numbers and per 100 000 of population. Results A total of 15,759 women in Bulgaria were diagnosed with cervical cancer in 2018. Morbidity is 23.5 of 100 000 population. Mortality of malignancy of the cervix in 2018 per 100 000 populations was 8.4 among women. Differences of mortality have been recorded as per statistical regions. A low immunization range has been recorded of vaccine against human papilloma virus (HPV) - 7.2% (girls 13 years of age) and 12.8% (girls 12 years of age) for first dose and 11.9% (girls 12 year of age) for second dose in 2019. Conclusions High morbidity and mortality from cervical cancer were registered in Bulgaria. The immunization coverage was low. The strategy for disease prevention through mandatory screening and mandatory immunizations needs to be rethought.

Leiomyomas are the most common benign gynaecological tumors and are one of the most frequent reasons for hysterectomy worldwide. We present a 36-year-old nulliparous Caucasian woman, with complaints of severe and painful menstrual bleeding, dyspareunia for 6 months. A pelvic formation, measuring 5/28 cm was diagnosed. Because of the potential malignancy risk, the tumor size and the location non-standard combined double abdomino-vaginal surgical approach was used. There are many operative techniques described in the literature depending on size, location and number of the myomas as well as on patient’s preferences; there are still clinical situations that remain challenging to choose the best surgical approach. In cases, when the standard methods for myomectomy are not considered appropriate, the option for an individual non-standard approach has to be discussed.

IntroductionMalignant melanoma is one of the most malignant tumours in the human body. Radical re-excision of the tumour bed is a principal part of its surgical treatment. We aim to test the hypothesis that the re-excision with a 2 cm margin in all directions to the scar from the previous biopsy of the primary tumour provides sufficient local control in patients with this disease.Material and methodsThis is a prospective descriptive study using STROBE methods, including all 151 patients with malignant melanoma of the skin, diagnosed and treated at the Department of Plastic, Reconstructive, and Aesthetic Surgery, Dr Georgi Stranski University Hospital, Medical University of Pleven, Bulgaria, in the period 2012–2016. Twenty-one cases were omitted from the study during the observation period due to lack of sufficient data. The re-excision was mainly within 2 cm margins in all directions to the scar from the previous biopsy of the primary tumour.ResultsData of all 130 patients with malignant skin melanoma, diagnosed and treated at our single large centre, were prospectively registered and analysed. These were 67 male and 63 female patients with a mean age at diagnosis of 61.6 years (range: 17–91 years). Using the re-excision within 2 cm margins, we identified only 1 (0.77%) patient with a histologically confirmed residual tumour in the re-excised flap. Local recurrence was observed in 13 (10%) patients.ConclusionsRe-excision with a 2 cm margin is sufficient to achieve local surgical radicalness in the treatment of this disease without compromising oncological survival.

The cancer of uterine cervix is one of the most common carcinomas in women. This morbid entity can frequently take its course synchronously with other benign and malignant diseases of the female reproductive system. We present a case of 57-year-old woman with cancer of uterine cervix, in whom a formation in the lesser pelvis was diagnosed by accident - it was preoperatively accepted as a large myoma, but, subsequently, it was found to be fibroma of the ovary. These concomitant diseases can result in difficulties when performing of the volume of surgery for the main diseases and intraoperative complications.