Benign adrenal cyst presenting in a pregnant patient.

Cystic lesions of the adrenal gland are uncommon, most often diagnosed incidentally during diagnostic imaging or autopsy. An adrenal cyst presenting as a pelvic mass in pregnancy offers the clinician a diagnostic and therapeutic dilemma. A 28-year-old black female presented for routine obstetric care at 26 weeks' gestation and was found on examination to have a 40-cm pelvic-abdominal mass. Ultrasound confirmation revealed the mass to be cystic and arising from the right pelvis. Laboratory tests including hematocrit, white blood cell count, electrolytes, rapid plasma reagin (RPR), and CA-125 were within normal limits. The patient underwent exploratory laparotomy and a 40 x 20 cm right adrenal cyst was identified and resected. Postoperatively, the patient developed preterm labor and delivered a 955-g infant; the infant was discharged home 3 months later with bronchopulmonary dysplasia and delayed developmental milestones. The woman was discharged home without complication on postoperative Day 8. Accurate preoperative determination of the origin of a pelvic mass occurring in pregnancy is helpful in timing therapeutic intervention. Use of ultrasound and magnetic resonance imaging (MRI) modalities can provide detailed anatomical information without risk to mother or fetus. Conservative management of adrenal cyst in pregnancy may lower the morbidity and mortality of the mother and fetus.

Steroid cell tumor associated with primary amenorrhea and virilization.

A 22-year-old woman sought medical advice because of primary amenorrhea and virilization that was manifested by facial hirsutism, temporal balding, and clitorimegaly. Plasma steroid levels were determined at the time of initial assessment; androstenedione and testosterone were increased in comparison with normal values. Vaginal ultrasonography revealed the presence of a mass localized to the right ovary. The patient underwent oophorectomy, and pathologic examination of the surgical specimen led to the identification of a steroid cell tumor associated with a polycystic ovary. Tumor steroid-metabolizing enzymes were evaluated in vitro: 17alpha-hydroxylase, 3beta-hydroxysteroid dehydrogenase/ delta5-->4-isomerase, 17beta-hydroxysteroid oxidoreductase, and 5a-reductase, which are required for androgen synthesis, were present in the tumor tissue. Postoperatively, plasma androstenedione and testosterone levels returned to normal. This study demonstrated that the tumor was the source of the increased levels of androgen precursor and androgen in this woman; excess tumor-derived androgen may have been the trigger in the development of the polycystic ovary.

Arias-Stella reaction in fallopian tube epithelium. A light and electron microscopic study with a review of the literature.

Most pathologists are familiar with the Arias-Stella reaction in the endometrium, because it is seen in approximately 25% of curettage specimens during early pregnancy. However, the Arias-Stella reaction is exceedingly rare in the fallopian tube, and may be confused with herpetic infection or malignancy. This may result in unnecessary therapy. The authors present a case of Arias-Stella reaction in the fallopian tube and discuss the differential diagnosis of this condition.

Cisplatin based combination chemotherapy in the treatment of stage III ovarian epithelial tumors of low malignant potential.

Eleven patients diagnosed with Stage III epithelial ovarian tumors of low malignant potential were treated with a combination of cisplatin and cyslophosphamide with or without doxorubicin following primary cytoreductive surgery. Residual disease after initial cytoreduction was macroscopic in nine patients and not observable in two. Eight of the nine patients with macroscopic residual were assessed by second look laparotomy (one refused the procedure), seven showed tumor and one was found to be a complete responder. Of the two patients with no residual disease, one refused second look operation and one had a negative second look. Our findings plus those of other authors suggest that cisplatin based combination chemotherapy is of limited value in the treatment of metastatic ovarian epithelial tumors of low malignant potential.

Marjolin's ulcer: a review and reevaluation of a difficult problem.

The formation of an epidermoid carcinoma in nonhealing scar tissue, a Marjolin's ulcer, is a well described neoplasm. These lesions are, however, frequently overlooked and often inadequately treated. This paper reviews six cases of scar-tissue carcinoma. All lesions were secondary to various kinds of burns. Four of the Marjolin's ulcers were well-differentiated squamous cell carcinomas. One was a moderately differentiated squamous cell carcinoma, and one was a malignant melanoma. The average age at presentation was 59 years, and the mean interval from time of burn injury to appearance of neoplasm was 36.8 years. The lesions varied in anatomic location and involved the upper extremities, lower extremities, and scalp. In addition to the case studies, this paper reviews the literature and provides a logical treatment plan for a patient with a Marjolin's ulcer. Because these lesions can be very aggressive, a well thought-out treatment plan is necessary to optimize care and assure patient survival.

Cost-effectiveness of cimetidine maintenance therapy in chronic gastric and duodenal ulcer.

The effects of cimetidine maintenance therapy on the socioeconomic life of patients with peptic ulcers in the 3 years after healing and the extent to which treatment was cost-effective were studied. Three hundred eleven patients with healed ulcers (184 gastric, 127 duodenal) were studied for periods of up to 3 years; 261 patients (152 gastric ulcer, 109 duodenal ulcer) completed the 3-year follow-up. Cimetidine (400 mg at night) was compared with placebo in a double-blind, randomized prospective study. Intention-to-treat analysis was used. In the placebo group, the major costs of ulcer disease in gastric ulcer patients were attributable to endoscopic procedures and absenteeism; in duodenal ulcer patients, the major costs were endoscopic procedures, absenteeism, and surgery. Cimetidine was cost-effective in both gastric ulcer and duodenal ulcer patients in the first 2 years after healing. Over the 3-year period it was also cost-effective, but no benefit was seen in the third year.

Adenosquamous carcinoma of the cervix: prognosis in stage IB.

The outcome of women with adenosquamous carcinoma of the cervix has been a controversial issue. To assess the prognostic significance of this cell type, the medical records of 29 patients with stage IB primary adenosquamous carcinoma of the cervix were reviewed. Twenty-six had cervical tumors measuring 3 cm or less. With a median follow-up of 60 months, the overall disease-free 5-year survival was 85%. Pelvic lymph node metastases were found in three of 19 patients (16%) with stage IB, and periaortic lymph nodes were negative in eight. A log-likelihood chi 2 test comparing lymphatic spread, recurrence rate, and 5-year disease-free survival in patients with stage IB disease and tumors less than 3 cm versus a similar group of 58 patients with pure squamous cell carcinoma of equivalent stage and comparable size treated during the same time disclosed no significant differences in any of the indicators analyzed. We conclude that stage IB adenosquamous carcinoma of the cervix does not differ in its metastatic potential or outcome from the more common pure squamous cell carcinoma.

Endodermal sinus tumor of the ovary: a paradoxical response to chemotherapy.

A patient with ovarian endodermal sinus tumor metastatic to the liver responded unusually to chemotherapy. She experienced histologically documented regression of all intraperitoneal disease with the exception of the liver metastases when given vinblastine, bleomycin, and cisplatin. She eventually died of liver failure. A review of patients with ovarian endodermal sinus tumor who either presented with initial liver metastases or had recurrent disease in the liver leads us to conclude that the liver is a preferential site for spread, that liver metastases carry an ominous prognosis, and that failure to see prompt liver metastatic tumor response after systemic chemotherapy should signal a need for a more aggressive therapeutic approach to the liver lesions.

Ovarian involvement in extragenital cancer.

Ovarian involvement from extragenital cancer often presents clinically as probable primary ovarian neoplasm. A retrospective review of the 29 such cases at Parkland Memorial Hospital from 1962 to 1985 was analyzed looking at clinical, surgical, and pathological parameters. The most frequent primary sites were colon (52%), breast (17%), stomach (10%), and pancreas (10%). Most common presenting symptoms were abdominal pain in 48% and increased abdominal girth in 45%. Preoperatively a palpable pelvic mass was detected in 93% and clinical ascites in 41% of patients. At surgery only 20% of patients had isolated ovarian metastases. Abdominal exploration identified the original tumor in 84% of the cases in which the primary originated in the abdomen. Bilateral ovarian involvement was found in 60%, and in 33% of these the contralateral involvement was occult. Eighty-three percent of patients have died with a median survival of 6 months. We conclude that mode of presentation, physical findings, and intraoperative assessment of patients with secondary ovarian neoplasms are no different from primary ovarian malignancy, and that when evaluating a pelvic mass, consideration should always be given to the possibility of secondary ovarian neoplasms.

Magnetic resonance imaging determination of myometrial invasion in endometrial carcinoma.

Fifteen patients with FIGO stage I biopsy confirmed endometrial adenocarcinoma underwent preoperative pelvic magnetic resonance imaging (MRI) to evaluate the presence and depth of myometrial invasion. Imaging was performed with a Diasonics superconducting imaging system operating at 0.35 T (15 MHz); multislice multi-spin-echo pulse sequences were used exclusively, with 5-mm contiguous sections. All patients then received primary therapy consisting of abdominal hysterectomy and bilateral salpingo-oophorectomy. Imaging findings were then compared with the uterine specimen histopathology. MRI was accurate in predicting the presence or absence of invasion in 13 of 15 cases (87%) and was able to discriminate superficial from deep invasion in 9 of 11 cases (82%). Based on our findings, we conclude that MRI appears to be an excellent technique for determining myometrial invasion, and that it may play a significant role in the preoperative planning of a thorough search for lymphatic spread in those patients considered to be at high risk by virtue of myometrial invasion.

Immature (malignant) teratoma of the fallopian tube.

Primary immature (malignant) teratoma of the fallopian tube is an extremely rare occurrence. We report such a case, which appears to be the third reported in the literature.

Primary staging in ovarian tumors of low malignant potential.

Surgical staging, consisting of peritoneal washings for cytology, infracolic omentectomy, and biopsies of diaphragm, extrapelvic peritoneum, and pelvic and aortic lymph nodes, was performed in 29 patients with ovarian tumors of low malignant potential, presumed to be either Stage I (25) or Stage II (4), in order to determine the incidence of unsuspected metastases in patients with localized disease. Fourteen patients had all and fifteen patients had one or more of these procedures performed. Overall, in stages I and II, positive peritoneal cytology was found in 7%, unexpected omental metastases in 13%, diaphragmatic metastases in 7%, positive pelvic lymph nodes in 27%, and positive aortic lymph nodes in 7%. Seven out of 29 (24%) patients with presumed localized disease, were upstaged by virtue of the staging procedures. Based on our findings, we conclude that surgical-pathologic staging to search for occult metastases in ovarian tumors of low malignant potential is justified from an investigational standpoint: however, its impact on therapeutic management is far from being defined.

Breast cancer metastasizing to the uterine cervix.

Three cases of breast cancer that metastasized to the uterine cervix are presented. A review of the literature disclosed 21 additional cases. Seventy-five percent of the patients presented with abnormal vaginal bleeding, 62% had no gross evidence of malignancy on examination, and in 89% the cervical metastases were a manifestation of widespread disease.

Canine model for long-term evaluation of prosthetic mitral valves.

The evaluation of mechanical prosthetic heart valves would be aided by a more satisfactory animal model. For acute assessment, a variety of animals have been used, but for chronic studies, only larger animals (pigs, calves, baboons) have been employed, creating an expensive model with laboratory management difficulties. Previously, the use of dogs for chronic evaluation has been unsatisfactory because of the frequent occurrence of early sepsis and valve-related thrombotic deaths. We have modified our existing acute dog protocol to produce a successful chronic model. Our model employs perioperative systemic antibiotics, short cardiopulmonary bypass period (range 35-60 min), a minimum of perioperative intravenous lines, postoperative anticoagulation therapy, and strict postoperative antiseptic technique for blood sampling. To evaluate this model, 11 consecutive mongrel dogs underwent mitral valve replacement with either a standard Dacron sewing skirt or a newly devised carbon-coated Teflon sewing skirt No. 23 mm Bjork-Shiley Convexo Concave (CC) prosthetic valve. Nine animals (82%) survived and were evaluated after a predetermined observation interval of either 3 or 6 months for valve function, pannus formation, and possible carbon particle migration. At sacrifice, all animals had good hemodynamics and valve function, minimal pannus formation and no carbon washout. Consequently, this model provides a relatively inexpensive, reproducible method of chronic in vivo evaluation of prosthetic valve modifications.

Mucosal pseudolipomatosis of the colon.

Twenty-four cases of a lesion characterized by unlined spaces in the colorectal lamina propria are presented. While lesions such as this have been reported previously as "lipomatosis" of the colon, histochemical and ultrastructural examination reveals that they are not, in fact, composed of adipocytes. It appears that they may be composed of gas trapped in the lamina propria. Because of their gross and microscopical similarity to fat, however, the term "pseudolipomatosis" is proposed.