Primary retroperitoneal mucinous cystadenocarcinoma of low malignant potential: a case report and literature review

A case of primary retroperitoneal mucinous cystadenocarcinoma of low malignant potential in the presence of normal ovaries is reported. The precise etiology of these neoplasms has not been defined; however, they may arise from heterotopic ovarian tissue, monodermal teratomas, embryonal urogenital remnants, intestinal duplication, or coelomic metaplasia. Although minimal data exist to define the appropriate management, it seems reasonable to extrapolate from the treatment of analogous ovarian neoplasms.

Absence of cumulative bone marrow suppression in heavily pretreated ovarian cancer patients undergoing salvage chemotherapy with paclitaxel

This retrospective study was undertaken to investigate whether paclitaxel was associated with cumulative bone marrow toxicity in patients undergoing salvage chemotherapy for refractory ovarian cancer. Seventy-seven patients were treated with paclitaxel 135 mg/m2 every 21 days, with granulocyte-colony-stimulating factor (G-CSF) support as necessary according to standard criteria. The mean white blood cell nadir was significantly higher and the incidence of severe leukopenia (Gynecologic Oncology Group grade 3-4) significantly lower after ten cycles than after the first cycle for the entire study population (3.4 vs. 1.6 x 10(3)/mm3 and 29 vs. 77%, respectively) and the patients who received G-CSF (3.5 vs. 1.4 x 10(3)/mm3 and 33 vs. 89%, respectively), but did not differ significantly for the patients who did not require G-CSF (2.9 vs. 2.5 x 10(3)/mm3 and 40 vs. 59%, respectively). The mean hematocrit and platelet nadirs, as well as the incidence of severe anemia and thrombocytopenia, did not differ significantly after ten cycles from those after the first cycle for the entire study population and both subgroups. Thirty-two (42%) patients received G-CSF, each initiated within four cycles. The indications for initiating G-CSF support were febrile leukopenia (53%) and treatment delay (47%). The average duration of G-CSF support was 4.6 days, and did not increase significantly as the number of paclitaxel cycles increased. We conclude that paclitaxel was not associated with cumulative bone marrow toxicity in patients undergoing salvage chemotherapy for refractory ovarian cancer.

Neovaginal cytology after total pelvic exenteration for gynecological malignancies

Vaginal reconstruction has become an established method to restore sexual function in women who have undergone ultraradical surgery and/or irradiation for the treatment of gynecologic malignancies. Cytologic evaluation of the neovagina serves a major role in the detection of recurrent disease. The purpose of this retrospective 6-yr study (January 1987-December 1993) was to evaluate the cytologic features of vaginal smear specimens from neovaginas constructed utilizing split-thickness skin grafts. Thirty-four vaginal smears were obtained at regular intervals from nine women (mean age: 51 yr) who underwent total pelvic exenteration with vaginal reconstruction for recurrent malignancies of the vagina and the cervix. Anucleated, keratinizing squames were a constant finding in each smear. Over a 4-mo-6-yr postoperative period, superficial and intermediate squamous cells were present in the majority of the smears and the maturation index showed a shift to the right. In two cases, a squamous cell carcinoma of the cervix recurred within the neovagina. Knowledge of the cytologic features associated with neovaginas is important in order to distinguish normal changes from neoplastic lesions.

Retroversion of the proximal humerus in relationship to prosthetic replacement arthroplasty

Arthroplasty of the proximal humerus positions a prosthetic articular surface in relation to the humeral canal. Most descriptions of surgical technique recommend positioning the humeral component in 30 degrees to 45 degrees of retroversion. This study measured retroversion in relationship to the surgically reamed canal and introduced a method of measurement pertinent to prosthetic reconstruction. The canals of 21 cadaveric humeri were surgically reamed, the articular margins of the humeral heads were outlined with steel wire, and the trochlear axes were transfixed with Steinman pins. Under fluoroscopy the humeri were rotated on a jig that allowed rotation around the reamer and measurement of retroversion relative to the plane of the articular surface. Retroversion of the proximal humerus is highly variable, ranging in this study from 10 degrees to 55 degrees (mean 29.8 degrees). Anatomic reconstruction of the retroversion angle must be individualized. Palpation of the rotator cuff insertion is recommended prior to humeral head resection to avoid inadvertant cuff injury.

cAMP and PMA enhance the effects of IGF-I in the proliferation of endometrial adenocarcinoma cell line HEC-1-A by acting at the G1 phase of the cell cycle

The present study was undertaken to determine whether endometrial cancer cell line HEC-1-A differ from nontransformed cells, in that the cAMP and protein kinase C pathways may enhance IGF-I effects in mitogenesis by acting at the G1 phase of the cell cycle instead of G0. Immunofluorescence staining of HEC-1-A cells using the proliferating cell nuclear antigen (PCNA) monoclonal antibody and flow cytometric analysis determined that HEC-1-A cells do not enter the G0 phase of the cell cycle when incubated in a serum-free medium. Approximately 51% of the cells were in G1, 12% were in S and 37% in G2 phase of the cell cycle prior to treatment. Forskolin and phorbol-12-myristate 13-acetate (PMA) were used to stimulate cAMP production and protein kinase C activity, respectively. IGF-I, forskolin and PMA each increased (P < 0.01) [3H]-thymidine incorporation in a dose and time dependent manner. The interaction of forskolin and PMA with IGF-I was then determined. Cells preincubated with forskolin or PMA followed by incubation with IFG-I incorporated significantly more (P < 0.01) [3H]-thymidine into DNA than controls or any treatment alone. It is concluded that forskolin and, to a lesser extent, PMA exert their effect at the G1 phase of the cycle to enhance IGF-I effects in cell proliferation.

Exponential regression of CA 125 during salvage treatment of ovarian cancer with taxol

The role of serum CA 125 in monitoring the response of epithelial ovarian cancer to treatment has been extensively investigated. The exponential regression curve [1n(CA 125) = i+s (days after initiation of treatment)] has been reported to describe the rate of change of serum CA 125 during treatment. In this model, the y-axis intercept (i) represents the initial CA 125-secreting tumor burden, while the slope (s) is determined by the response to treatment. The exponential regression curve was calculated for 66 patients undergoing salvage chemotherapy with taxol. At a mean follow-up of 121 days, 50 (75%) patients had progressed and 35 (53%) had died. Stratification of the patients by stage, grade, or histology did not reveal any significant differences in the regression rate. When the patients were stratified by response, the mean regression rate was 0.0157 +/- 0.011 for patients with progressive disease (N = 19) vs -0.0250 +/- 0.031 for those with stable disease (N = 25) and -0.0250 +/- 0.015 for those with a partial response (N = 22) (P < 0.0001). The regression rate did not correlate with progression-free interval or survival (P > 0.05). We conclude that changes in serum CA 125 levels follow an exponential regression curve in patients undergoing salvage chemotherapy with taxol for progressive or recurrent ovarian cancer. A positive regression rate may predict which patients will progress prior to the time progression becomes clinically evident. However, a negative rate fails to provide discriminatory utility in predicting progression-free interval or survival.

Open laparoscopy without special instruments or sutures. Comparison with a closed technique

An important advantage of open laparoscopy over closed techniques is the avoidance of placing a sharp trocar blindly into the peritoneal cavity. Although an open technique theoretically minimizes the risk of major retroperitoneal vessel injury and bowel injury, most laparoscopies are performed using a closed technique. In an effort to simplify open laparoscopy, a technique was developed that can be done without special equipment or sutures and nearly as quickly as a closed technique. To compare the effectiveness of this open laparoscopic technique to a closed technique, a prospective, observational, cohort study was carried out on 66 women undergoing laparoscopy for either infertility or pelvic pain. The open technique was performed on 35 consecutive patients and compared to a closed technique performed on 31 patients on a different service during the same period. Evaluation included total duration of the procedure, length of the incision, incidence of CO2 leakage and complications. The open technique took slightly longer, and the incision was slightly longer. CO2 leakage occurred in 5 of 35 of the open cases but in none of the 31 closed cases. Leakage was controlled effectively in every case by application of a towel clip to the skin incision. No complications occurred with either technique. This study suggested that an open technique that requires no special equipment or sutures may be a useful alternative approach for laparoscopy when insertion of a sharp trocar is undesirable.

Synchronous dual primary ovarian and endometrial carcinomas

OBJECTIVES

The synchronous occurrence of carcinoma confined to the ovary and endometrium presents a diagnostic and therapeutic dilemma. These tumors have been variously staged as FIGO Stage IIA ovarian carcinoma, Stage III endometrial carcinoma, or synchronous dual primary carcinomas. Accumulating evidence suggests such patients have a favorable outcome. This retrospective study was undertaken to review our experience with these fascinating tumors.

METHODS

The clinical records and the pathologic findings of 16 patients with synchronous dual primary ovarian and endometrial carcinomas were reviewed.

RESULTS

The median age was 51 years. Abnormal uterine bleeding was the most common presenting symptom (70%). All patients had Stage I ovarian and endometrial carcinomas. Fourteen patients (88%) had endometrioid carcinoma in both sites, while two patients (12%) had dissimilar histology. For 15 patients (94%), the grade of both tumors was identical. Only three (19%) patients had myometrial invasion, with less than 50% involvement in each case. All patients underwent surgical staging, 11 (70%) of whom received adjuvant radiation or chemotherapy. The five patients treated with surgery alone had Grade 1 endometrioid tumors. The only relapse occurred in a patient with a clear cell component in both sites. No patient has died of disease.

CONCLUSIONS

Patients with synchronous dual primary carcinomas appear to have a more favorable prognosis than that expected with Stage IIA ovarian or Stage III endometrial carcinoma (100% vs. 63% or 42% survival at 3 years, respectively). The excellent survival for patients with Grade 1 dual endometrioid tumors treated with surgery alone suggests that adjuvant therapy may not be necessary for this sub-group.

Vaginal delivery from the persistent occiput posterior position. Influence on maternal and neonatal morbidity

We performed a retrospective study of 564 vaginal occiput posterior (OP) deliveries to investigate the influence of this position on maternal and fetal morbidity. The cases were compared to 1,068 controls matched for race, parity and delivery method. The OP group had a higher incidence of severe perineal laceration and episiotomy than the occiput anterior (OA) group. Within the OP group, operative delivery was associated with a higher incidence of severe perineal laceration, vaginal laceration and episiotomy than was spontaneous delivery. Similarly, the OP group delivered by forceps had a higher incidence of severe perineal lacerations, vaginal lacerations and episiotomy than those delivered by vacuum extraction. Mediolateral episiotomy was associated with a lower incidence of severe perineal lacerations than median episiotomy during delivery from the OP position. The infants delivered from the OP position had a higher incidence of Erb's and facial nerve palsy than did those delivered from the OA position. All these injuries occurred following forceps delivery. Vaginal delivery from the persistent OP position is associated with increased maternal morbidity, and operative vaginal delivery from this position is associated with increased neonatal morbidity.

Incontinence following rupture of the anal sphincter during delivery

OBJECTIVE

To determine the frequency with which patients report incontinence of flatus or stool after rupture of the anal sphincter during delivery.

METHODS

A chart review and telephone interview were conducted with 70 primiparas, 35 of whom had rupture of the anal sphincter at delivery and 35 of whom did not. All were contacted 9-12 months postpartum and questioned about the development of incontinence of gas or liquid or formed stool, persistent dyspareunia, and perineal pain.

RESULTS

Incontinence of gas was reported by six women (17%) in the rupture group and one (3%) in the control group (P < .05). The incidence of incontinence of stool, both liquid and solid, dyspareunia, and persistent perineal pain were similar between the groups.

CONCLUSION

Incontinence of flatus was reported six times more often by women who experienced a third- or fourth-degree perineal laceration than by those without anal sphincter rupture.

Laparoscopic injury of abdominal wall blood vessels: a report of three cases

BACKGROUND

Operative laparoscopy is being used for an increasing number of applications. Many of these innovative techniques require the insertion of large trocars through the anterior abdominal wall at points lateral to the midline. Because of the rich vascular supply of the anterior abdominal wall, the incidence of abdominal wall vessel injuries appears to be increased by these techniques.

CASES

Three cases are reported in which abdominal wall blood vessels were injured during operative laparoscopy. Case 1 describes laceration of the inferior epigastric artery above the pubic crest. Despite initial hemostasis with a transabdominal suture ligation, postoperative blood loss necessitated transfusion and reoperation to control bleeding. Case 2 describes hematoma formation after unrecognized injury to one of the epigastric vessels. The hematoma resolved without sequelae with conservative treatment. Case 3 describes hematoma formation under a laparoscopic trocar incision lateral to the umbilicus that progressed to an abscess and was treated with drainage, irrigation, and antibiotics.

CONCLUSIONS

Choosing appropriate trocar types and insertion sites based on a thorough understanding of anterior abdominal wall anatomy may minimize the risk of vessel injury during operative laparoscopy. However, because of anatomical variation, strategies for managing vessel injuries and their sequelae are also necessary.

Mitogenic activity of growth factors in the human endometrial adenocarcinoma cell lines HEC-1-A and KLE

Endometrial adenocarcinoma is the most common gynecologic malignancy occurring in the United States. Evidence is accumulating that links peptide growth factors with malignant proliferation. Epidermal growth factor (EGF) and insulin-like growth factor I (IGF-I) are known mitogens for endometrial adenocarcinoma in vitro. However, the biological activity of other growth factors in this malignancy is unclear. This study was undertaken to determine the influence of growth factors on the mitogenic activity of the human endometrial adenocarcinoma cell lines HEC-1-A and KLE. Incubation with EGF, IGF-I, insulin-like growth factor II (IGF-II), or insulin stimulated a time-dependent mitogenic response in both cell lines, with the peak response occurring at 24 hr for HEC-1-A and 48 hr for KLE. After two doubling intervals, the number of HEC-1-A cells was increased 3.5-fold by EGF (100 ng/ml), 2.7-fold by IGF-I (100 ng/ml), 2.3-fold by IGF-II (100 ng/ml), and 2.2-fold by insulin (1000 ng/ml) when compared to untreated controls (P < 0.05). The number of KLE cells was increased 2.6-fold by EGF (100 ng/ml), 2.3-fold by IGF-I (100 ng/ml), 2.1-fold by IGF-II (100 ng/ml), and 2.0-fold by insulin (1000 ng/ml) when compared to untreated controls (P < 0.05). Similar results were obtained when DNA content was measured. PDGF failed to stimulate any mitogenic response in either cell line at all concentrations tested (0.1-100 ng/ml). These findings suggest that EGF, IGF-I, IGF-II, and insulin may play a regulatory role in the proliferation of endometrial adenocarcinoma.

Routine endometrial curettage is not indicated at the time of cervical cone biopsy

Endometrial currettage is commonly performed after cervical cone biopsy to detect occult endometrial abnormalities. Recently, this practice has been questioned and specific criteria promulgated to reduce the number of concomitant endometrial curettages performed at the time of cone biopsy. To investigate the reliability of these criteria, we reviewed the records of 370 women who underwent cold-knife cervical cone biopsy, 323 (87.3 percent) of whom underwent concomitant endometrial curettage. Significant endometrial abnormalities were present in only 18 women, each of whom met at least one specific criterion for endometrial currettage. In contrast, 23 endometrial currettings either contained cervical tissue (five patients) or were insufficient for diagnosis (18 patients). The incidence of complications directly attributable to endometrial curettage was 1.6 percent. We conclude that limiting endometrial curettage at the time of cone biopsy to those women meeting specific criteria would significantly reduce the number of endometrial currettings performed, without hindering the ability to detect significant endometrial abnormalities. Such a reduction would minimize surgical morbidity and could save $13 million annually in the United States.

Humeroscapular positions in a shoulder range-of-motion-examination

Positions of the arm are traditionally described in relation to the thorax. Yet shoulder pathology most often lies in and about the glenohumeral joint, which then becomes the focus of treatment. Little is known about the relative motion between the humerus and the scapula primarily because there is no clinically accepted method for assessing and describing these positions. This paper proposes a clinical method for describing and measuring humeroscapular positions based on an anatomic definition of the plane of the scapula. Humeroscapular positions achieved by 75 normal subiects during a conventional (humerothoracic) shoulder range-of-motion examination are presented. Identification of the plane of the scapula is based on four palpable anatomic landmarks: (7) the inferior pole of the scapula, (2) the medial border of the scapula at the level of the scapular spine, (3) the posterolateral corner of the acromion, and (4) the tip of the coracoid. The plane of the scapula is defined by the line connecting the first two of these points and a point midway between the last two. Humeroscapular positions are specified by the plane of elevation and the angle of elevation in relation to this mobile scapular plane. Measurement of these positions was done with a goniometer facilitated by a "scapula-locating device" designed for this study. Maximal humerothoracic elevation of the arm was achieved with the humerus lust behind the scapular plane at 90° of humeroscapular elevation. Cross-body adduction positioned the humerus in a plane 51° anterior to the plane of the scapula, with most of the cross-body motion occurring between the scapula and thorax. External rotation at 90° of elevation in the coronal plane of the body (the apprehension position) positioned the humerus in a plane 17° posterior to the scapular plane. Humerothoracic extension and reaching up the back took place at very low angles of humeroscapular elevation.

An electromyographic analysis of the shoulder during cones and planes of arm motion

Shoulder motion has traditionally been described in reference to arbitrarily defined planes of motion (e.g., sagittal/flexion, coronal/abduction). This study examined shoulder muscle recruitment during conical arm movements, which include all planes of motion. Electromyographic (EMG) data was collected with intramuscular wire electrodes from ten muscles in five normal volunteers. Each muscle showed peak EMG activity in association with a direction of action consistent with its anatomic alignment. These findings were similar for movements in both the sagittal and coronal planes, calling into question conventionally held designations of shoulder muscles as flexors and abductors. Muscle recruitment was as follows: Clavicular pectoralis major, to move the arm medially along the horizontal; anterior deltoid, to move the arm obliquely upward inclined toward the midline; middle deltoid, to move the arm obliquely upward inclined away from the midline; posterior deltoid, to move the arm laterally along the horizontal; and teres major and latissimus dorsi, to move the arm obliquely downward away from the midline. Rotator cuff muscles were maximally active during elevation, consistent with the concept of a force couple.

Diffuse adenomatoid tumor of the uterus with a serosal papillary cystic component

A 39-year-old woman undergoing immunosuppressive therapy following kidney transplantation for systemic lupus erythematosus presented with a uterine adenomatoid tumor that diffusely infiltrated the entire myometrium and contained a serosal papillary cystic component that resembled a cystic mesothelioma. This is the first reported case of an adenomatoid tumor showing both of these features. Although adenomatoid tumors are considered benign, the patient may be at risk for recurrence of the papillary cystic component (which is known to recur in 50% of cases) if this tumor reflects an inability to limit neoplastic processes.

Percutaneous transcatheter embolization for control of life-threatening pelvic hemorrhage from gestational trophoblastic disease

Pelvic hemorrhage from gestational trophoblastic disease remains a common and vexing problem. Traditional surgical therapy, including hysterectomy and hypogastric artery ligation, may be technically difficult as well as hazardous to debilitated patients. In contrast, percutaneous transcatheter embolization specifically occludes the vessels that directly contribute to bleeding. Other potential advantages include avoidance of general anesthesia and major surgery, a rapid recovery period, and preservation of fertility. Various embolic materials allow one to tailor the duration of occlusion to the underlying disorder. Reported complications are rare and generally involve aberrant emboli or inadequate collateral circulation leading to ischemic injury. We believe that transcatheter embolization should be considered an alternative to operative intervention for control of pelvic hemorrhage from gestational trophoblastic disease.

The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique

OBJECTIVE

We evaluated the location of the umbilicus relative to the aortic bifurcation and the left common iliac vein where it crosses the midline.

METHODS

Abdominal computed tomography images from 35 reproductive-age women were retrospectively reviewed to determine the location of the umbilicus. The results were correlated with body mass index using Pearson correlation coefficient and a two-tailed paired t test.

RESULTS

The location of the umbilicus, but not the aortic bifurcation, was more caudal in heavier women and negatively correlated with body mass index. In nonobese women, the mean location of the umbilicus was 0.4 cm caudal to the aortic bifurcation, and was at or cephalad to the bifurcation in eight of 15 (53%). In overweight women, the mean umbilical location was 2.4 cm caudal to the bifurcation, and in obese women, 2.9 cm caudal to the bifurcation. In the last two groups of subjects, the umbilicus was located at the level of the bifurcation in six of 20 (30%). In every case, the umbilicus was located cephalad to where the common iliac vein crossed the midline.

CONCLUSIONS

The umbilicus is often located at or cephalad to the aortic bifurcation, and consistently located cephalad to where the left common iliac vein crosses the midline. The laparoscopic approach should take these relationships into account to minimize injuries to major retroperitoneal vessels.

A system for describing positions of the humerus relative to the thorax and its use in the presentation of several functionally important arm positions

The function of the shoulder is to position the arm with respect to the thorax. Humerothoracic positions are commonly described in terms of the degrees of humeral elevation in the sagittal plane (flexion) and/or the degrees of elevation in the coronal plane (abduction). This article proposes a more general system for describing positions of the arm based on the plane of humeral elevation and the angle of elevation within this plane. This system is used to present the humerothoracic positions used by eight normal subjects to perform several activities of daily living as well as those achieved in a range-of-motion examination of the shoulder. Eating, hair combing, and maximal elevation were all performed in a plane approximately 60° anterior to the coronal plane. Between reaching the perineum and washing the contralateral axilla, the humerus functioned in a range of planes extending over 180°.

Fibroepithelial polyps of the vagina in pregnancy

A 38-year old pregnant woman presented with a polypoid tumor of the vagina. A biopsy revealed benign fibroepithelial polyps. Her pregnancy progressed normally, and she underwent an uncomplicated vaginal delivery. Once the benign nature of the lesion has been established, a spontaneous vaginal delivery is not contraindicated. However, operative vaginal delivery should be avoided to reduce the risk of trauma and hemorrhage. Local excision is curative and may be performed as an interval procedure when the vaginal vascularity has returned to normal.