Adequacy of oophorectomy at the time of gynecologic surgery.

OBJECTIVES: To determine the incidence of incomplete ovarian removal during gynecologic surgery and correlate the risk of inadequate removal with the procedure chosen. METHODS: This is a prospective observational study. Ovaries received during a 4-month period in the participating institutions were independently histologically evaluated. Gross inspection of the ovarian capsule, infundibulopelvic ligament, hilum and utero-ovarian ligament was assessed. Grossly close margins were confirmed histopathologically. Any margin with histologically confirmed ovarian tissue at the margin was interpreted as incompletely removed. Details of each surgical procedure were recorded for comparison. RESULTS: Ovaries (n=174) from 94 patients were collected and 155 were evaluable. The overall incidence of incomplete ovarian removal was 6.5%. Of the 125 ovaries removed abdominally, 23 were laparoscopically assisted and 7 were vaginal; inadequate removal was documented in 5%, 9% and 29%, respectively (P=0.04). There was no relationship of inadequate resection by underlying pathologic diagnosis (P=0.25) or by institution (4.6% university hospital vs. 8.8% community hospital; P=0.29). CONCLUSIONS: Incomplete ovarian removal occurs and is related to surgical approach. A larger study is warranted to evaluate the role of pelvic pathology or surgeon experience as a risk for incomplete oophorectomy.

Pathology slide review in gynecologic oncology.

OBJECTIVE: To analyze the diagnostic accuracy and alteration in treatment planning from interinstitution (different institution) pathologic consultation. METHODS: We reviewed pathologic reports from 720 referred patients. The diagnosis rendered from a gynecologic pathologist was compared with the original diagnosis. Discrepancies were coded as none, minor, or major. A discrepancy was major if it led to treatment alteration. A discrepancy was minor if it did not lead to treatment alteration. The judgment to declare a discrepancy was made by a gynecologic pathologist, a gynecologist, and three gynecologic oncologists. The review cost was $150 per case. The Cochran-Mantel-Haenszel test evaluated any systematic pattern in discrepancies. RESULTS: Seven hundred twenty specimens consisted of 113 vulvar, 170 uterine, 289 cervical, 105 ovarian, and 43 vaginal tissues. Six hundred one (84%) pathologic diagnoses showed no discrepancy. There were 104 (14%) minor and 15 (2%) major discrepancies. After reviewing 15 major discrepancies, six surgeries were canceled, two surgeries were modified, one adjuvant radiation treatment was added, one chemotherapy treatment was modified, and five adjuvant chemotherapy treatments were cancelled. No systematic error was identified with regard to the sources (tissue origin) or methods of obtaining the specimen (P = .675). The cost of reviewing 720 specimens was $108,000. The cost of identifying each major discrepancy was $7200. CONCLUSION: Reviewing pathology slides before definitive treatment reveals notable discrepancies in diagnoses. The cost of pathology review is globally expensive but has consequential impact on proper treatment planning for the individual patient.

Analysis of tissue margins of cone biopsy specimens obtained with "cold knife," CO2 and Nd:YAG lasers and a radiofrequency surgical unit.

Analysis of the tissue margins of cone biopsy specimens obtained from 40 patients showed varying degrees of thermal and mechanical artifact at the tissue margins. The least artifact was seen in the tissue margins of specimens obtained with the scalpel ("cold knife"). The amount of thermal damage to biopsies obtained via lasers and the radiofrequency unit varied with the instrument employed. However, the quality of the tissue margins of specimens obtained using a radiofrequency surgical unit equipped with a needle electrode on a "pure cut" setting approached the quality of those obtained with the cold knife in their lack of thermal and mechanical artifact.

Combined intrauterine and ovarian pregnancy. A case report.

A case of combined ovarian and intrauterine pregnancy occurred. The ovarian pregnancy was an incidental finding during cesarean section. A literature survey revealed only 17 cases of combined ovarian and intrauterine gestation.

Prevalence of papillomarvirus infection in colposcopically directed cervical biopsy specimens in 1972 and 1982.

A total of 1264 consecutive cervical biopsy specimens obtained at the Parkland Memorial Hospital Dysplasia Clinic during 1972 were reviewed. Histopathologic specimens were assessed with special reference to changes induced by human papillomavirus. In 1972, only 0.7% of biopsy specimens were reported as consistent with human papillomavirus infection. Upon review, however, 36.5% of these specimens were found to demonstrate histologic criteria for the diagnosis of human papillomavirus infection. Approximately half of biopsy specimens reclassified as human papillomavirus were originally interpreted as inflammation; the others were interpreted as cervical intraepithelial neoplasia. Patients with human papillomavirus infection were significantly younger than patients with cervical intraepithelial neoplasia (24.9 versus 30.2 years). These findings were compared with 965 cervical biopsy specimens obtained in 1982. Thirty-four percent of these biopsy specimens revealed human papillomavirus infection. These observations support the concept that human papillomavirus infection of the cervix is not a new entity but a previously unrecognized finding whose prevalence has been relatively stable over a 10-year period.

Xanthogranulomatous oophoritis: an inflammatory pseudotumor of the ovary.

A case of xanthogranulomatous oophoritis is presented. The patient is a 26-year-old woman who had a 10-year history of pelvic inflammatory disease. The pathogenesis of this lesion appears similar to that of xanthogranulomatous pyelonephritis. Ultrastructural findings are presented and xanthogranulomatous lesions of the female genital tract are reviewed.

Adenoid cystic carcinoma of Bartholin's gland. Case report and review of the literature.

A patient with adenoid cystic carcinoma of Bartholin's gland is reported and the literature relevant to this disease reviewed. The clinical presentation is characterized by a vulvar mass that has existed for a prolonged period prior to the onset of symptoms, usually infection, pain, and burning. Histologically the tumor is characterized by a cribriform pattern and perineural invasion. Electron microscopy confirms the epithelial nature of this lesion. Conclusions concerning therapy are presented, including emphasis on initial radical vulvectomy and the fact that the efficacy of routine lymphadenectomy and adjuvant radiotherapy has not been demonstrated.

Transformation of "signet ring cell" lymphoma to typical nodular, poorly differentiated lymphocytic lymphoma: light microscopic, immunohistochemical and electron microscopic observations.

Malignant lymphoma with intracellular immunoglobulins giving a "signet ring" appearance to the lymphocytes is a recently described morphologic variant with specific ultrastructural and immunohistochemical characteristics. We report a case that had this distinctive morphology when initially biopsied but on subsequent biopsy 2 1/2 years later had the typical appearance of a poorly differentiated lymphocytic lymphoma without "signet ring" cells. The same monoclonal immunoglobulin class and light chain type was demonstrated in both biopsies using immunohistochemical techniques. Rare cells in the second biopsy showed the characteristic ultrastructural findings. These findings support the concept of a continuum of cell types in malignant lymphoma, with transformation toward a cell line lacking the peculiar characteristics resulting in this unique appearance.

Primary carcinoma of the Bartholin gland: a report of 14 cases and review of the literature.

Fourteen cases of primary carcinoma of the Bartholin gland were treated between 1955 and 1980. Follow-up information was available on all patients. Ten patients have survived free of disease for 5 or more years. Three patients with positive inguinal lymph nodes have survived 5 years. Histological patterns and lymph node involvement are analyzed. The authors' data and a review of the literature support the concept that radical vulvectomy with bilateral inguinal-femoral lymphadenectomy is required for all histologic types of Bartholin gland carcinoma. Routine pelvic lymph node dissection is not necessary when the inguinal-femoral nodes are negative for metastases.

Primary clear cell adenocarcinoma of the fallopian tube: light microscopic and ultrastructural findings.

The first reported case of primary clear cell adenocarcinoma of the fallopian tube is presented. The patient, a 52-year-old female, was post-menopausal and presented with anemia and a pelvic mass. The presence of this histologic type in the fallopian tube is consistent with the mullerian origin of this tumor.

Steroid secretion by masculinizing and "feminizing" Hilus cell tumors.

The clinical course, histology, and steroid secretion observed in two patients with hilus cell tumors are presented. One patient had signs of virilism and the other had estrogenic signs only. Steroid secretion was examined by measuring peripheral and ovarian venous gradients and pre- and postoperative levels of hormones to explain the profound differences in the biological effects exerted by the neoplasms. In the patient with virilism, the tumor's major secretory product was testosterone (T), and the dominant biosynthetic pathway was pregnenolone (Pe) leads to 17-hydroxypregnenolone leads to 17-hydroxyprogesterone leads to androstenedione (delta) leads to T. In the patient with estrogenic signs, the major secretory product was delta, derived from a similar pathway of pregnenolone leads to 17-hydroxypregnenolone leads to 17-hydroxyprogesterone leads to delta. Circulating estrone and estradiol levels were elevated, but the tumor showed limited aromatase activity, as reflected by 60- to 1500-fold larger peripheral-ovarian venous gradients of delta and T than estrone and estradiol. The high circulating estrogen levels mainly arose from the peripheral aromatization of the increased secretion of delta by the tumor. It was concluded that a similar steroidogenic pathway was employed by both tumors. The predominant secretion by the neoplasm of either T of delta was determined by the presence and the oxidation reduction equilibrium of the 17 beta-dehydrogenase enzyme. The action of this enzyme resulted in profound differences in the biological effects exerted by these tumors.

An unusual mechanism for a fistulous communication between the aorta and right side of the heart.

A case of infective endocarditis is reported in which a fistulous communication developed from the septal tricuspid valve leaflet, throught the membranous ventricular septum, into the non-coronary aortic cusp. From a nidus of infection in the uterus, the tricuspid valve was seeded, leading eventually to the fistula. The particular course of the perforation avoided conduction system damage until late in the clinical course, when idioventricular rhythm and eventual cardiac arrest supervened.

Nodular lymphoma with intracellular immunoglobulin.

A case of malignant lymphoma with vacuolated cells is presented and, as with two other recent reports, is of the nodular poorly differentiated lymphocytic type. This form of malignant lymphoma presumably is composed of neoplastic B lymphocytes, which produce intracellular immunoglobulins or fractions thereof, corresponding to various cellular vacuoles and inclusions. The vacuolated appearance of the neoplastic cells simulates mucinous or "signet ring" adenocarcinoma, which may be excluded by clinical, routine microscopic, histochemical, immunologic, and electron microscopic observations.