Spontaneous pneumothorax management.

Guidelines for the management of spontaneous pneumothorax were published by the British Thoracic Society (BTS) in 2003. The aim of our study was to assess compliance with the BTS guidelines. A retrospective review was performed on all spontaneous pneumothoraces admitted to our hospital between June 2006 and December 2007. There were 29 pneumothoraces during the study period, 20 of which were primary spontaneous pneumothoraces (PSPs). All 15 (100%) large PSPs had an intercostal drain (ICD) inserted with a mean calibre of 20Fr, however only 1 of the 15 (6.7%) had a prior attempt at aspiration. High flow oxygen was used in 3/20 (15%) PSPs and 1/9 (11%) secondary spontaneous pneumothoraces (SSPs). 5/6 (83%) of large SSPs had ICDs placed with a mean calibre of 23.3Fr. Compliance with BTS guidelines was suboptimal. In particular, simple aspiration was underutilised with an over-reliance on unnecessary tube thoracostomy. Moreover, the calibre of intercostal drains used was in excess of BTS recommendations. This study highlights the need to formally adopt BTS guidelines, thereby establishing a more standardised practice which should improve management of spontaneous pneumothoraces.

Trophoblastic peritoneal implants after laparoscopic treatment of ectopic pregnancy.

Persistent trophoblastic activity after salpingostomy for ectopic pregnancy implies the presence of intra-abdominal trophoblastic tissue, usually within the fallopian tube. We report a case of disseminated trophoblastic peritoneal implants, presenting as hemoperitoneum three weeks after laparoscopic salpingectomy. Only 23 such cases have been reported. Surgical treatment of ectopic pregnancy, especially by the laparoscopic technique, may cause intraperitoneal spread and reimplantation of trophoblastic tissue. Precautions for minimizing this complication are discussed.

Elevated serum alkaline phosphatase may enable early diagnosis of ovarian cancer.

A case of endometrioid ovarian carcinoma associated with elevated levels of serum placental-like alkaline phosphatase (PLAP) is presented. Two and a half years before a final diagnosis was made following explorative laparotomy, an incidental blood test revealed elevated alkaline phosphatase in the patient's serum. A thorough investigation for the source of this elevation was negative. Postoperative immunohistochemical staining of the tumor, showed diffuse stain with PLAP, along with gradual decline to normal values of serum total alkaline phosphatase. It is suggested, that whenever serum alkaline phosphatase is elevated due to unknown reason, an investigation including alkaline phosphatase isoenzymes, serum Ca-125, trans-vaginal pelvic sonogram and even diagnostic laparoscopy, should be considered in a search for early preclinical ovarian cancer.

Diagnostic dilemmas and current therapy of Fallopian tube cancer.

Primary tubal cancer, unlike ovarian cancer, is not routinely suspected preoperatively, and thus diagnosis and therapy are delayed. We have recently encountered two cases in which primary Fallopian tube cancer masqueraded as other lesions. One presented as a pelvic inflammatory process, the second as cervical cancer. Primary Fallopian cancer should be suspected by the clinician, even if the presenting symptoms are atypical. Chemotherapy with taxol and cisplatin was instituted following debulking surgery.

Conservative treatment of adenocarcinoma of the endometrium in young patients. Is it appropriate?

Few reports have suggested that nulliparous young patients with endometrial cancer may be treated conservatively to preserve fertility. We present a young nulliparous woman with a well differentiated adenocarcinoma of the endometrium treated with progestins. Since she did not respond, a definite operation was performed revealing involvement of the uterine isthmus, thus necessitating adjuvant radiotherapy.

Sertoli cell tumor causing precocious puberty in a girl with Peutz-Jeghers syndrome.

Distinctive ovarian and cervical tumors are associated with Peutz-Jeghers syndrome (PJS). The most common gynecological tumors in this syndrome are adenoma malignum of the uterine cervix and ovarian sex cord tumor, particularly sex cord tumor with annular tubules (SCTAT). Other kinds of ovarian tumors have been rarely reported in association of PJS, including Sertoli cell tumors. We report a case of a 4.5-year-old girl with PJS who presented with isosexual precocious puberty (IPP) due to ovarian lipid-rich Sertoli cell tumor. In addition to estrinizing effect of the tumor, the patient had decidual reaction secondary to tumor-derived progesterone secretion. The literature on gonadal tumors in PJS is reviewed, including one previous report of ovarian lipid-rich Sertoli cell tumor associated with this syndrome.

Clinical-pathological study of uterine leiomyomas with high mitotic activity.

OBJECTIVE: To evaluate clinical-pathological aspects of mitotically active leiomyomas. STUDY DESIGN: Twenty patients with smooth muscle tumors of the uterus, with 5-9 mitotic figures per 10 high power fields and without atypia or necrosis were studied. The clinical and pathological characteristics of these tumors were reviewed and analyzed. RESULTS: Patients' ages ranged from 33 to 63 years (mean 42.5 years). The size of the tumors ranged from 1.5 to 9.5 cm (mean 5.4 cm). On gross examination all tumors appeared as typical leiomyomas. Treatment included hysterectomy in 16 patients and myomectomy in four. Follow-up periods ranged from 1.5 to 11 years (mean 6.8 years). None of the patients developed a recurrent tumor. CONCLUSION: The benign clinical behavior of such tumors supports their current designation as mitotically active leiomyomas, thus deleting the previous misnomer 'smooth muscle tumors of uncertain malignant potential'. Myomectomy is an appropriate treatment, particularly in young patients interested in reproduction.

Unsuspected uterine leiomyosarcoma discovered during treatment with a gonadotropin-releasing hormone analogue: a case report and literature review.

We report a case of a 37-year-old woman who had received five courses of gonadotropin-releasing hormone (GnRH) agonist (Decapeptyl) for presumed uterine leiomyomata associated with episodes of uterine bleeding. Submucous myoma (histologically proven) was partially removed on the first visit. After a period of significant reduction in the tumor size and cessation of uterine bleeding, the symptoms recurred along with rapid re-growth of the uterus. Total abdominal hysterectomy was performed and the pathologic evaluation revealed leiomyosarcoma with a high mitotic rate. This case and the literature review emphasize the problems encountered with the early diagnosis of uterine leiomyosarcoma during GnRH agonist therapy.

Serological and immunohistochemical determinations of p53 protein in diagnosis of endometrial cancer: a comparative study.

BACKGROUND: The role of different methods for the determination of p53 protein was evaluated for the detection of endometrial cancer in humans. METHODS: p53 antigen was detected immunohistochemically in the cell nuclei of endometrial tumors and serologically in the serum of the same patients. The high performance liquid chromatography (HPLC) technique was used to measure serum levels of p53 protein after its partial purification on gel fiberglass affinity chromatography columns. RESULTS: Image analysis of cellular concentrations of p53 protein revealed an increase from 12% in hyperplastic endometrium to 74% in adenocarcinomas. Image analysis has also revealed a strong correlation between cellular concentrations of p53 antigen and tumor grade (r = 0.54). Visual cell determination of p53 antigen was effective mainly among patients with benign lesions (r = 0.61). There was a positive correlation between cellular concentration of p53 protein in tumor tissue and its serum level in cancer patients (r = 0.44). The serum level of the cytoplasmic form of p53 antigen significantly increased in cancer patients (3 mg/ml) compared to the concentration in patients with benign disorders (0.7 mg/ml); a consequence of its higher concentration in tumor cells. Serum level of p53 antigen was highly active both in patients with non-cancerous lesions (r = 0.42) and in patients with cancer (r = 0.51). Diagnostic significance of tissue concentrations of estrogen and progesterone applies only to cancer patients: coefficients of correlation between these parameters and tumor gradation were 0.58 and 0.89, respectively. CONCLUSIONS: Serum determination of cytoplasmic p53 antigen can reveal this oncoprotein in the early stages of cancer, or even foretell its development.

[Destructive tuberculous osteoarthritis of the shoulder in the elderly].

Osteoarthritis (OA) due to tuberculosis (TB) is rare. The usual sites are the spine and weight-bearing joints, while joints such as the shoulder are less often affected. In recent years there has been a resurgence of TB, the rate of increase of extrapulmonary surpassing that of pulmonary TB. The elderly, especially residents of nursing homes, are at increased risk for active TB. The course of the disease is characterized by insidious development, and systemic involvement is usually not noted. Months or even years may elapse before the correct diagnosis is made, sometimes only after irreversible damage. We present an 82-year-old woman with TB OA of the shoulder, illustrating the importance of this curable disease in the differential diagnosis of chronic monarthritis.

Epidermoid cyst of the spleen: a cytokeratin profile with comparison to other squamous epithelia.

The stratified squamous epithelium of a splenic epidermoid cyst was studied with a battery of monoclonal antibodies to cytokeratin (CK) proteins. CKs 10 and 11 were found in the suprabasal layers of the stratified squamous epithelium, while staining for CK 13 was focal or diffuse throughout. CKs 18 and 19 decorated individual squamous cells or stained the entire thickness of the epithelium. These results were compared with those previously obtained by us in stratified squamous epithelia of ovarian mature cystic teratoma, fetal epidermis, adult epidermis and squamous metaplasia in a peritoneal cyst. From these comparisons it emerges that the epidermoid splenic cyst is either of teratomatous derivation or originates from inclusion of fetal squamous epithelium. Squamous metaplasia of mesothelium or inclusions of mature squamous epithelium appears to be an unlikely source of origin of these cysts.