Primary umbilical endometriosis: case report and literature review.

We present a case of primary endometriosis of the umbilicus in a young nulliparous patient without any previous history of abdominal or pelvic surgery. Primary endometriosis of extra pelvic sites is unusual while umbilical endometriosis is quite rare. Diagnosis of endometriosis is difficult to obtain and sometimes diagnoses can be false-positive or false-negative. Some imaging procedures can be done to rule out other disorders but it is difficult to differentiate them from endometriosis. A definite diagnosis can only be established by histopathological examination. Hematoxylin and eosin (H&E) is the staining of choice. Conservative surgical excision of the lesion and drugs such as oral contraceptives and gonadotropin releasing analogues are the first-line treatment.

Effect of the portacaval shunt on reperfusion injury after 65% hepatectomy in pigs.

BACKGROUND: Portal flow diversion by portacaval shunts (PCS) has been shown to prevent primary graft nonfunction in liver transplantation using small-for-size grafts. In this study, we examine whether PCS can improve reperfusion injury after major hepatectomy in pigs. MATERIALS AND METHODS: In 14 pigs, a partial PCS was constructed following 65% hepatectomy and 1 h of inflow ischemia. During 24 h of reperfusion, the shunt was either closed (group A, n = 7) or left open (group B, n = 7). RESULTS: 24 h after reperfusion, group A had higher levels of alanine aminotransferase (70 +/- 12 IU/l vs. 51 +/- 5.9 IU/l; p < 0.05), alanine aminotransferase per gram of liver remnant (0.41 +/- 0.07 IU/l/g vs. 0.21 +/- 0.05 IU/l/g; p < 0.05), prothrombin time (24.1 +/- 2.4 s vs. 14.3 +/- 2.9 s; p < 0.05), international normalized ratio (2.11 +/- 0.15 vs. 1.29 +/- 0.28; p < 0.05), hepatocyte necrosis scores and percentages of nuclei stained for proliferating cell nuclear antigen (52.57 +/- 8.9% vs. 36.71 +/- 6%; p < 0.05) compared to group B. CONCLUSIONS: Partial portal flow diversion appears to attenuate reperfusion injury in a porcine model of major hepatectomy.

Primary gestational choriocarcinoma of the uterine cervix. Report of a case and review of the literature.

Gestational choriocarcinoma usually arises in the uterine cavity and is associated with coincident or antecedent pregnancy. Extrauterine choriocarcinomas are very rare entities, and most of these are located in the uterine cervix. In our case, a 43-year-old woman was admitted in our hospital because she had amenorrhea for 2 months and elevated serum beta-human chorionic gonadotropin levels. The patient was considered to have an ectopic pregnancy. Initially, she was treated with methotrexate, but since there was a continuous rise in human chorionic gonadotropin levels, the patient underwent a laparoscopy, along with dilatation and curettage (D&C) of the uterine cavity. Histopathologic findings, including immunohistochemical study, led to the diagnosis of choriocarcinoma of the cervix. Finally, the patient underwent a transabdominal hysterectomy and received single agent chemotherapy with methotrexate. Our case represents a primary choriocarcinoma of the cervix, which was initially misdiagnosed as an ectopic pregnancy. The difficulties in differential diagnosis are discussed. Immunohistochemical evaluation remains the mainstay of the diagnosis in most cases. Choriocarcinoma has a very good prognosis even in advanced stages, since it is a very chemosensitive tumor.

Low-grade endometrial stromal sarcoma of the endocervix. Report of a case and review of the literature.

Cervical sarcomas are rare entities comprising 0.5% of all primary cervical malignancies. Endometrial stromal sarcoma (ESS) is the least common (< 10%) type of uterine sarcoma. It has traditionally been divided into two categories: low-grade stromal sarcoma (LGSS), which constitutes 50-60% of all ESS, and high-grade stromal sarcoma (HGSS). Low-grade ESS may arise in extrauterine locations, classically described as arising in foci of endometriosis. In our case, a 44-year-old woman presented with a 4-week history of abnormal vaginal secretions and occasional bleeding. Physical examination revealed a soft, hemorrhagic mass on the posterior cervix, approximately 7 x 4 x 3 cm, looking like a degenerated myoma. The patient underwent a radical hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic lymphadenectomy. Histopathological findings, including immunohistochemical study, led to the diagnosis of a LGSS of the endocervix, which was in close relation with endometriotic foci. Our case represents an extrauterine low-grade ESS arising in the endocervix, where a problem in the differential diagnosis was encountered and which was finally treated only with surgery. Adjuvant treatment of ESS is controversial. Generally, low-grade ESS is associated with good prognosis and long overall and disease-free survival.

Spectroscopic characterisation of carotid atherosclerotic plaque by laser induced fluorescence.

BACKGROUND AND OBJECTIVE: An effort has been made to distinguish the composition of carotid atherosclerotic plaques (CAP) from patients undergoing carotid endarterectomy, by laser induced fluorescence spectroscopy. STUDY DESIGN/MATERIALS AND METHODS: Different excitation wavelengths were used: 476, 488, and 458 nm of a continuous wave krypton/argon ion laser, and 337 nm of a pulsed nitrogen laser. Twenty-three CAP samples from different patients were investigated and several spectra from each plaque were obtained. RESULTS: Results were crossed-examined with conventional histologic techniques, which showed three areas of different composition on the pathologic samples: fibrous tissue, lipid constituents, and calcified plaque. Gaussian fittings were performed to reproduce the fluorescence spectra as a correlation of multiple Gaussian curves. CONCLUSION: The accuracy for discrimination of the heterogeneous composition of the atherosclerotic plaque is still limited, due to superposition of the fluorescence emission of various plaque components.

Duodenal gangliocytic paraganglioma as a radiological moving defect.

BACKGROUND: Gangliocytic paraganglioma of the duodenum is a peculiar neuroendocrine tumor, often revealed as an incidental radiographic finding or as a result of gastrointestinal hemorrhage, due to frequent ulceration of the overlying mucosa. Most lesions are pedunculated and submucosal with distinctive histology, consisting of endocrine, ganglion and spindle-shaped Schwann cells. METHODS: A case of a duodenal gangliocytic paraganglioma is reported in a 50-year-old woman presenting with episodes of melena. Enteroclysis revealed a pedunculated tumor observed either in the second or third portion of the duodenum. Upper gastrointestinal endoscopy revealed a pedunculated ulcerated tumor which was subsequently confirmed by computed tomography. The tumor was simply excised through a duodenotomy. RESULTS: The size of the tumor was 4.5 x 3 x 1.5 cm. Immunohistochemical and ultrastructural features of the tumor classified it as a typical duodenal gangliocytic paraganglioma with positive cellular reaction for neuron-specific enolase, chromogranin, somatostatin, gastrin and S100. CONCLUSION: Forty-six months after surgery, the patient is well with no evidence of recurrence. The majority of the reported duodenal gangliocytic paragangliomas were of benign nature. However, the fact that in 4 isolated cases there was lymph node involvement indicates that thorough investigation for lymph node metastases is needed, as well as thorough postoperative follow-up.

Aberrant pancreas in the gallbladder wall.

We present three cases of heterotopic pancreas in the gallbladder wall. The patients (all female) presented with abdominal pain. Ultrasonography revealed polypoid tumor with coexistence of lithiasis in two cases. All patients underwent cholecystectomy. Microscopy revealed chronic cholecystitis and cholesteatosis and heterotopic pancreatic tissue. Heterotopic pancreas in the gallbladder wall is a rare heterotopia, with 23 cases reported in the international literature.

Somatostatin receptor scintigraphy of non-neuroendocrine malignancies with 111In-pentetreotide.

In-111 pentetreotide is a new radiolabelled [OctreoScan 111, Mallinckrodt Medical BV, Petten] somatostatin analog with high affinity to somatostatin receptors (SR). introduced for the in vivo imaging of SR positive tissues. In an attempt to evaluate its clinical usefulness for tissue characterization in malignancies without neuroendocrine expression in parallel with histological and radiological examinations, specific scintigraphy was performed on brain (6 cases), thyroid (6 cases) and breast (9 cases) tumors, and in lymphomas (9 cases) and melanomas (6 cases). A dose of 111MBq of In-111 pentetreotide was injected i.v. to each patient and scintimages at 6 and 22 hours (for comparison) p.i. were obtained. The primary lesion of the breast cancer population was imaged in all 9 cases as well as all the palpable axillary nodes in 4 cases. Three women with impalpable axillary lymph nodes scanned negative but had a positive biopsy. Both meningiomas were positive for SR scans: positive results were also obtained for the high grade astrocytoma and the craniopharyngioma: Two out of 6 patients with papillary thyroid cancer showed a marked radiotracer accumulation. Scintigraphy in all 5 lymphomas was positive for SR but did not detect the Tc-99m sulphur microcolloid [Lymphoscint, Solco, Basel, Suitzerland] imaged lymph nodes in 5 melanomectomized patients. When judging the imaging results of these non-neuroendocrine malignancies definite conclusions should not be drawn since the number of studied cases polymorph, was small for every cancer histotype; nevertheless SR scintigraphy does not seem to be reliable for tumor staging in non-neuroendocrine malignancies, but is more suitable for a tissue characterization and monitoring changes of SR expression during and after therapy.

Two phase scintigraphic mapping of lymphatic drainage in cutaneous melanoma using 99mTc-sulfur microcolloid/99mTc antimelanoma antibody.

The purpose of lymphoscintigraphy in patients with melanoma before surgery is to image the lymphatic drainage net and particularly to detect the sentinel node; the purpose of immunolymphoscintigraphy after surgery is to map the lymphatic drainage and to detect a possible spead of the malignancy towards the lymph nodes surrounding the surgical field or more distal regions. The aim of the present study was to assess the sensitivity of a two-phase procedure with Tc-99m-Iabelled agents for exploring possible spread of melanoma after thorough resection of the primary lesion. Seven melanomectomized patients were enrolled into the study. The melanomas were situated on the head, back, arm and buttock of these patients. Intracutaneous lymphoscintigraphy with Tc-99m sulphur microcolloid [Lymphoscint, Solco, Basel, Switzerland] and i.v. immunoscrintigraphy with Tc-99m-antimelanoma antibody [Tecnemab-K-I, Sorin Biomedica Spa, Saluggia, Italy] at a dosage of 55 MBq and 740 MBq respectively, were performed in 13 patients to define possible infiltration of lymph nodes after surgery with a time interval of 1 week between the two examinations. Tc-99s sulphur microcolloid preceded the Tc-99m anti-melanoma antibody scan. The scintigrams were evaluated by three experienced nuclear physicians. The method detected 3 out of 16 suspicious nodes as malignant. Combined two-phase technique improves the diagnostic and staging accuracy of cutaneous melanoma affected population and appears extremely useful in the surgical confrontation of the lymphatic spead.

Palliative therapy using rhenium-186-HEDP in painful breast osseous metastases.

The efficacy and toxicity of treatment with 1400 +/- 100 MBq of Re-186-HEDP were evaluated in women with osseous metastatic breast cancer. The follow-up period was fourteen weeks. The efficacy of treatment was assessed by a) a pain and performance questionnaire that patients were asked to complete daily and b) a CT scan comparison of a randomly preselected osseous lesion before and 30 weeks after Re-186-HEDP i.v. application. The response to treatment was also evaluated by using the Kamofsky Index. Two out of fourteen women (14%) experienced loss of pain, 6 experienced obvious and 2 some improvement. No change was observed in 4 patients. Five patients manifested a flare response to treatment, with increase in pain within the first, 4 to 5 days after Re-186-HEDP administration. Five patients showed a decrease in platelet levels and absolute number of polymorphonuclear blood transfusion; no neurologic side effects were observed. Re-186-HEDP appears to be a useful new radiopharmaceutical for pain palliation induced by osseous metastases due to breast cancer. Compared to Sr-89 chloride efficacy, it provides longer-lasting analgesia, and when needed it can be reinjected with less risk due to its improved physico- and radiochemical properties.

Human papillomavirus identification and typing of both sexual partners.

OBJECTIVE: To investigate the efficacy of diagnostic methods for human papillomavirus (HPV) infection. STUDY DESIGN: The diagnostic methods were morphologic and immunohistochemical techniques and in situ hybridization. The first ones consisted of (1) a cytologic smear on the females, (2) cytologic examination of a urethral brushing on the males, (3) colposcopy on the females, and (4) histologic examination of the uterine cervix. RESULTS: A synchronous HPV infection was found in 50% of the sexual partners. HPV was detected also in 30% of cervical biopsies by immunohistochemistry. In situ hybridization was performed on both the cervical biopsies and urethral samples from the males. By this method the same subtype of the virus was observed in both sexes. The types of HPV were identified in 45% of 20 females and 80% of 20 males. Analytically, in men, 7 cases of HPV 6/11 types, 3 cases of 16/18, 5 cases of 31/33/35 and 1 case each of 16/18 and 31/33/35 were observed. In women, in 4 cases subtypes 6/11, in 2 cases types 16/18 and in 3 cases types 31/33/35 were identified. CONCLUSION: Male partners of women with HPV infection should be investigated in order to produce greater insight into HPV prevalence and the mechanisms of viral transmission.

Receptor scintigraphy of non-neuroendocrine cancers with In-111 pentetreotide.

Somatostatin receptors (SR) are surface markers characterizing not only APUDomas associated with neuroendocrine identities but also malignancies without neuroendocrine expression. Recently, the somatostatin analog pentetreotide was labeled with In-111 (OctreoScan 111, Mallinckrodt Medical BV, Petten, Holland) and introduced for the in vivo visualization in man of SR-positive tissues. In the present report, SR-specific scintigraphy is evaluated as a clinical tool for tissue characterization in correlation with histological and radiological examinations. Scintigraphy was focused and performed in cancer types without neuroendocrine tissue expression such as brain (n = 6) and breast tumors (n = 9) and lymphomas (n = 5). Scintigraphy was performed for comparison at 6 and 22 h after i.v. application of 111 MBq (3 mCi) of In-111-Pentetreotide. In the breast cancer group, the primary tumor was visualized in all 9 women as well as in all 4 cases with palpable axillary lymph nodes. Three women with a negative axillary node scan and impalpable nodes had positive biopsy. In two cases, mediastinal lymph node involvement was observed. So far the role of SR-positive breast cancer (BC) scans remains unknown. It is tempting to speculate that in resected women who are histologically and scintigraphically SR positive, it might be of value in the early detection of symptom-free recurrences. High densities of SR were present within both meningiomas, the high-grade astrocytoma and the craniopharyngioma. Differentiation of low- and high-grade astrocytomas could not be successfully achieved because both grades showed intense radioactivity uptake, even though high-grade tumors lack SR. The latter might be due to the damaged blood-brain barrier and the poor radioactivity washout observed in high-grade astrocytomas. All five lymphomas could be detected due to the presence of activated lymphocytes and macrophages that express SR at a sufficient density. In conclusion, SR scintigraphy in non-neuroendocrine malignancies does not seem to be reliable for an initial tumor staging but rather more suitable for a tissue characterization and extremely useful for monitoring changes of SR expression after treatment.

Ovarian surface serous papillary carcinomas: a clinicopathologic study.

Between 1982 and 1992, 129 patients with malignant epithelial ovarian tumors were reviewed with identification of 10 patients having surface papillary serous carcinoma of the ovary and one having peritoneal papillary carcinoma. The gross operative specimens, histopathologic condition, and treatment records were reviewed. All patients had disease involving the omentum, and the abdominal and pelvic peritoneum, and they all corresponded to stage III, according to FIGO. The median age at presentation was 58-years (age range, 43 to 73 years). All patients had a total abdominal hysterectomy and bilateral salpingo-oophorectomy, and all received chemotherapy. The median survival time for all patients was 15 months. Three patients are alive 3 to 4 years after the initial diagnosis. In conclusion, surface serous ovarian cancers and peritoneal papillary serous cancers have common histologic appearance and the same responsiveness to surgical therapy and to chemotherapy and should be treated similarly.

Blighted ovum: ultrasonic, histopathologic and hormonal considerations.

Thirty women experiencing early pregnancy failure (blighted ovum) were studied at frequent intervals with serial measurements of serum human chorionic gonadotropin (beta-hCG), progesterone (P4) and estradiol (E2). The diagnosis of blighted ovum had previously been made by careful ultrasonic examination (s). Histopathologic findings in the placenta were studied in all cases. Hormonal levels were variable and in most of the cases indistinguishable from normal pregnancies. In only 50% of the cases the histopathologic examination revealed findings compatible for the blighted ovum criteria.