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.

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.

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.

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.

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.