Falsely elevated human chorionic gonadotropin leading to unnecessary therapy.

BACKGROUND: Analysis of serum beta-hCG aids diagnosis and treatment of intrauterine pregnancies, ectopic gestations, and gestational trophoblastic neoplasia. beta-hCG concentrations are specific for trophoblastic tissue, thus are rarely questioned. CASES: An 18-year-old nullipara had bleeding and a positive beta-hCG. Ultrasound identified no pregnancy. She passed tissue and stopped bleeding. Serum beta-hCG remained elevated despite uterine curettage and three courses of methotrexate. Results of urine beta-hCG were negative, as was reference laboratory serum assay. A 31-year-old nullipara had a spontaneous abortion, but serum beta-hCG remained elevated. Uterine curettage found secretory endometrium, yet elevated serum beta-hCG persisted. Urine beta-hCG was negative, as was reference laboratory serum assay. CONCLUSION: Patients with histories incongruent with serum beta-hCG findings should have urine beta-hCG analysis.

The role of p27 in endometrial carcinoma.

OBJECTIVE: The cyclin-dependent kinase inhibitor p27 has been shown to mediate cell growth arrest in response to various environmental stimuli. p27 protein levels have shown prognostic value in several different types of cancer. We examined the prognostic value of p27 protein expression in endometrial cancer, the most common gynecologic malignancy. METHODS: A total of 95 paraffin-embedded tumor blocks were obtained and stained via immunohistochemical techniques with a monoclonal antibody against p27. Ten high-power fields were evaluated per slide with at least 1000 cells per slide and two slides per specimen evaluated by two reviewers for nuclear and cytoplasmic staining. The specimens were evaluated for associations with age, stage, grade, and histology. Statistical analysis was performed using the Student t test, chi(2) Kaplan-Meier, and likelihood ratios to assess the data and to generate P values. RESULTS: A total of 91 patients met inclusion criteria for statistical analysis. Fifty-three patients were stage I, 13 stage II, 14 stage III and 11 stage IV with a positive stain (>50% of cells) for p27 obtained in 32.1, 23.1, 35.7, and 36.4%, respectively (Student t test P = 0.77). Survival data were available on 24 advanced stage patients. p27 protein immunostaining showed no association with patient survival. We also found no association of p27 staining with age or histology. Notably, we found a trend in increasing staining with increase in grade, particularly with stage I patients. Also, there was an association of the nuclear and cytoplasmic staining and stage (P = 0.05), but it had no correlation with patient survival. CONCLUSION: Our study showed decreased p27 protein staining in endometrial cancers compared to normal endometrial cells. We found that p27 protein staining shows no association with stage, age, or histology and is not prognostic for survival in advanced endometrial cancers. However, there may be a trend associated with increased p27 protein staining with advanced grades of tumors.

Age-specific survival of women with endometrioid adenocarcinoma of the uterus.

OBJECTIVE: The purpose of this paper was to evaluate the age-specific survival for women diagnosed with endometrioid adenocarcinoma of the uterus. METHODS: A retrospective analysis was conducted of 328 patients diagnosed with endometrioid adenocarcinoma of the uterus between January 1990 and December 1997. Patients were followed for 3 to 96 months with a mean of 43 months. The impact of age on survival was assessed using Cox proportional hazard regression and multivariate analysis for age, stage, and grade. Stage and grade were analyzed using log-rank tests, and survival curves were generated by the Kaplan-Meier method. RESULTS: A total of 328 patients were evaluated. Multivariate analysis revealed age, stage, and grade were all significant independent predictors of survival (P < 0.0001). Age-specific survival varied from a high of 90% at age 40 to a low of 55% at age 80. Interval age-specific survival decreased below 86% at age 50. Subset analysis of patients younger than 50 compared with older patients revealed no difference in surgical stage or grade of tumors among these patients. Patients older than 50, however, were 41% more likely to receive adjuvant radiation therapy. CONCLUSION: Age is a specific, significant predictor of outcome in endometrioid adenocarcinoma of the uterus. Survival decreases significantly in patients older than 50. This decreased survival associated with age is unrelated to surgical stage or grade of adenocarcinoma. Decreased survival could involve molecular differences in the developing endometrial cancer or an increased risk of death from other non-cancer-related factors.

Primary peritoneal carcinoma presenting on routine papanicolaou smear.

BACKGROUND: Primary peritoneal carcinoma is an uncommon disease, characterized by peritoneal carcinomatosis without other identifiable primary tumor. It typically presents resembling ovarian cancer, with abdominal pain and distention and in an advanced stage. We report a unique presentation of this disease. CASE: A 76-year-old woman had severe glandular dysplasia on a screening Papanicolaou smear. An ectocervical lesion was biopsied, revealing moderately differentiated adenocarcinoma. Cervical stenosis prevented sampling of the endocervix and endometrium. Colonoscopy and mammography did not reveal malignancy. Total abdominal hysterectomy with bilateral salpingo-oophrectomy was performed. Surgery revealed surface implants on the pelvic organs, with minimal involvement of the ovaries. Histologic examination revealed adenocarcinoma with papillary serous differentiation. Surgical and microscopic findings were consistent with a diagnosis of primary peritoneal carcinoma. CONCLUSION: Primary peritoneal carcinoma usually presents in a manner similar to that of ovarian cancer, but atypical presentations also occur. While a Papanicolaou smear suggestive of carcinoma usually represents a primary cervical malignancy, this case serves as a reminder that other metastatic malignancies should be considered.

Recurrent squamous cell carcinoma of the Bartholin's duct treated with en bloc resection.

Bartholin's gland carcinomas are a rare entity. A case of a recurrent Bartholin's gland carcinoma is described. These neoplasms have a myriad of treatment options for primary therapy but there is a paucity of information regarding treatment for a lethal recurrence. The patient's primary therapy consisted of an initial wide local excision followed by radiation therapy with chemosensitization. She was disease-free for 2 years before her recurrence. A novel treatment approach incorporating a mulitdisciplinary en bloc radical surgery is described. The patient is alive and well without evidence of disease at 22 months.

Asymptomatic intussusception of the appendix due to endometriosis.

We present the case of a 29-year-old woman with an asymptomatic intussuscepted appendix found incidentally during surgical evaluation for a pelvic mass in a patient with endometriosis. This case represents the rare nature of this presentation and the need to fully evaluate the gastrointestinal tract in patients with endometriosis.

Myonecrosis of the rectus muscle after a Cherney incision.

BACKGROUND: The original description of the Cherney incision includes bilateral ligation of the inferior epigastric vessels to increase incision width [1]. However, in patients with compromised abdominal wall vasculature, ligation may lead to healing complications. CASE: Our patient experienced necrosis of the right rectus muscle after undergoing pelvic surgery via a Cherney incision. During the procedure, attempts were made to retain both inferior epigastric arteries, but the right was transected and ligated. Sepsis developed and myofascitis was diagnosed. The interesting radiographic findings of myofascitis are also presented. CONCLUSION: The vasculature of our patient's abdominal wall may have been compromised after four previous transverse abdominal incisions, and the ligation of the right inferior epigastric vessel may have contributed to postoperative complications.