Pathological Characterization of Ovarian Cancer Patients Who Underwent Debulking Surgery in Combination With Diaphragmatic Surgery: A Cross-Sectional Study

Despite exhaustive efforts to detect early-stage ovarian cancers, greater than two-thirds of patients are diagnosed at an advanced stage. Although diaphragmatic metastasis is not rare in advanced ovarian cancer patients and often precludes optimal cytoreductive surgery, little is known about the mechanisms and predictive factors of metastasis to the diaphragm. Thus, as an initial step toward investigating such factors, the present study was conducted to characterize the pathological status of ovarian cancer patients who underwent debulking surgery in combination with diaphragmatic surgery.This is a retrospective and cross-sectional study of patients who underwent debulking surgery in combination with diaphragmatic surgery at our institution between January 2005 and July 2015. Clinicopathological data were reviewed by board-certified gynecologists, pathologists, and cytopathologists. The rates of various pathological findings were investigated and compared by Fisher exact test between 2 groups: 1 group that was pathologically positive for diaphragmatic metastasis (group A) and another group that was pathologically negative for diaphragmatic metastasis (group B).Forty-six patients were included: 41 patients pathologically positive and 5 pathologically negative for diaphragmatic metastasis. The rates of metastasis to the lymph node (95.8% vs 20%, P = 0.001) and metastasis to the peritoneum except for the diaphragm (97.6% vs 60.0%, P = 0.028) were significantly increased in group A compared with group B. However, no significant differences between the 2 groups were found for rates of histological subtypes (high-grade serous or non-high-grade serous), the presence of ascites, the presence of malignant ascites, exposure of cancer cells on the ovarian surface, blood vascular invasion in the primary lesion, and lymphovascular invasion in the primary lesion.Our study demonstrated that metastasis to the lymph node and nondiaphragmatic metastasis to the peritoneum are significantly associated with metastasis to the diaphragmatic peritoneum, indicating that these factors may be pathological predictors of diaphragmatic metastasis in patients with ovarian cancer. However, as the data available are not sufficient to demonstrate the predictive power of these factors, a further comprehensive, large-scale study should be performed.     

Histology of the intestinal peritoneum in patients with cirrhosis of the liver and ascites

Portal hypertension and hypoalbuminemia are usually incriminated in the development of ascites in liver cirrhosis, and altered peritoneal permeability is considered only as a hypothetical possibility. Jejunal postmortem specimens were studied in 15 control patients and 16 patients dying with cirrhosis of the liver and ascites. In decompensated cirrhosis a fibrous thickening of the peritoneum was found, 159.0±96.4 m (mean±sd) compared to 24.5±10.6 m in controls (P<0.001). An increase in the size and number of blood vessels, lymphangiectasiae, and mononuclear cell infiltration were invariably present. These histological changes are consistent with a nonspecific chronic peritonitis. The findings indicate there is increased blood perfusion and lymph flow within the intestinal peritoneum in patients with decompensated cirrhosis of the liver and support the existence of an intestinal peritoneal factor in the pathogenesis of cirrhotic ascites.     

56例结核性腹膜炎患者CT影像分析

目的 探讨结核性腹膜炎（TBP）特征性CT影像表现及治疗中影像动态变化的特点。方法 回顾性分析56例临床及病理确诊的TBP患者,观察分析CT影像特征,包括腹腔积液、腹膜（壁腹膜、肝包膜、大网膜及肠系膜）及腹腔淋巴结。56例均行CT平扫+增强扫描。治疗过程中收集动态复查CT影像。结果 腹腔积液45例,大量1例,中少量44例,限制性38例,CT值>20 HU者34例。壁腹膜增厚46例,肝脏边缘部腹膜均有受累,均匀增厚17例,扁丘状凸起或腹膜结核瘤29例,增强扫描结核瘤边缘强化,肝包膜或肝脏受累15例;网膜增厚35例,结节及斑片34例,网膜饼1例,增强扫描网膜饼呈轻度不均匀强化;肠系膜增厚41例,表现为斑片、结节及线状、星芒状条索状高密度影,与肠袢粘连,增强扫描肠系膜血管包埋其内,走形扭曲。腹腔及腹膜后淋巴结增大19例,伴钙化5例,簇集状排列,增强扫描环状或蜂窝状强化。17例完整的动态CT图像,腹腔积液吸收最快,网膜及肠系膜病变吸收稍慢,腹膜结核瘤缩小速度最慢。结论 TBP的CT诊断为多种征象的综合,中少量腹腔积液伴壁腹膜、网膜及肠系膜的增厚粘连是最为常见的影像表现;CT影像动态变化对临床评价疗效具有重要意义。     

Pathogenesis of varices in schistosomal portal hypertension

Patients with schistosomiasis and portal hypertension have significantly lower levels of hydroxyproline in their saphenous veins and anterior rectus sheaths than do individuals without schistosomal hepatic fibrosis. The stomach of patients with schistosomal portal hypertension demonstrates an increased number of lymphatics by lymphangiography. The disrupted lymph node architecture in these patients could be partially responsible for dilation, tortuosity, and retrograde lymph flow in the gastric lymphatics. These histological and lymphangiographic findings could be attributed to the effect of venous and lymphatic hypertension. A postmortem histological examination of the esophagus of patients with decompensated schistosomal portal hypertension revealed edema of the entire esophageal wall with lymphatic dilation and tortuosity. Based upon these data, we suggest that the varices that develop in patients with schistosomal portal hypertension occur as a consequence of an increased portal venous pressure together with acquired lymphangectasia as well as an intrinsic weakness of the walls of the portosystemic venous channels.     

Hepatic intracellular sodium in schistosomal hepatic fibrosis.

This study was performed on 15 male non-ascitic schistosomal cases to estimate hepatic intracellular electrolytes content. Another 10 non-schistosomal non-cirrhotic cases were taken as control. It has been found that, serum sodium and potassium concentration and hepatic intracellular potassium content were within normal range with no statistical difference in the values obtained in both schistosomal and control group. The hepatic intracellular sodium content was higher than normal in all our cases, with a significant statistical difference between the schistosomal and the control group. It has been concluded that, in schistosomal patients increase in the intracellular sodium content is an early finding before the development of ascites.     

The effect of anesthesia and surgery on diaphragmatic lymph vessel flow after endotoxin in sheep

Increases in diaphragmatic lymph vessel flow (Qdi) may be important in preventing ascites because diaphragmatic lymph vessels drain the peritoneal space. However, lymphatic vessel function may be depressed in anesthetized, open chested animals. To test this hypothesis, we cannulated diaphragmatic lymph vessels in five sheep which were anesthetized with 1-2% halothane. We performed a thoracotomy and cannulated a diaphragmatic lymph vessel in each sheep. Then we infused 0.75-1.0 micrograms/kg of E. coli endotoxin intravenously and we measured Qdi and the lymph protein concentration for 2-4 hrs. The data were compared to previously reported data for five unanesthetized sheep (J. Appl. Physiol. 62:706-710, 1987). At baseline Qdi = 0.8 +/- 0.7 (SD) in the anesthetized sheep and 1.0 +/- 0.8 ml/hr in the unanesthetized sheep. After endotoxin, Qdi increased to 4.5 +/- 3.1 ml/hr in the unanesthetized sheep (p less than 0.05) but Qdi did not change in the anesthetized sheep. However, the lymph protein concentration increased similarly in each group, indicating that endotoxin caused the same degree of injury in each group. Our results indicate that diaphragmatic lymph vessel function is depressed in anesthetized, open chested sheep.     

Schistosomal colonic polyposis: clinical, radiological and parasitological study

One hundred and eight male Egyptian farmers with schistosomal colonic polyposis were reviewed. All patients gave a history of bloody diarrhoea. Sixty-one patients presented with finger clubbing, and four of these patients had painful, tender and swollen wrist, knee and ankle joints. X-ray revealed new bone formation in the bones around these joints. The clinical condition improved with antischistosomal treatment, but the bony changes persisted. Twenty patients showed signs of dependent oedema or ascites. Thirty-one patients had a liver of 8 cm or more below costal margin and 19 patients had a spleen of 8 cm or more below costal margin, a situation not unlike patients with schistosomiasis without polyposis. Fifteen patients had tender abdominal masses in the left iliac fossa which were shown by barium enemas to be clusters of polyps. Anti-schistosomal therapy relieved the obstruction but narrowing persisted in 70% of patients followed up. Severity of schistosomal colonic polyposis correlated with the anatomical distribution of the polyps, with their number and with the egg excretion rates.     

Study of chemical constituents of thoracic duct lymph in schistosomal hepatic fibrosis

Concentrations of serum and thoracic duct proteins, immunoglobulins, lipids, enzymes and electrolytes were estimated in 15 patients with schistosomal hepatic fibrosis and presinusoidal obstruction and in 12 controls. There was a significant decrease of thoracic duct total proteins, albumin and triglycerides, with marked and significant increase in IgG and IgM in SHF, compared to the controls. The levels of transaminases, alkaline phosphatases and inorganic phosphorus were significantly higher in the lymph of SHF patients compared with healthy controls. It is presumed that these changes represent the pattern of lymph constituents in presinusoidal obstruction.     

腹膜活检52例分析

对52例不明原因的腹水及腹块病人用Vim Silverman双分叶片状针经皮、腹腔镜直视下及腹部小切口开窗腹膜活检,诊断率分别为6.7％、93.3％和100％.其中结核性腹膜炎19例,腹膜转移癌16例,腹膜间皮瘤1例,16例未获得诊断。作者认为,腹腔镜直视下腹膜活检和腹部小切口开窗活检对腹内肿瘤性或结核性疾病的鉴别诊断有重要价值.并对其适应症、优缺点进行了讨论.     

Case report: hepatic hydrothorax without ascites

Pleural effusion due to hepatic cirrhosis and ascites is well known. We describe three patients with right-sided hepatic hydrothorax in the absence of ascites. The formation of pleural fluid in these patients is probably a result of fluid movement from peritoneal to pleural space across diaphragmatic defects before ascites can form. The differential diagnosis of a right-sided transudative pleural effusion in a patient with chronic liver disease with or without ascites includes congestive left ventricular failure and nephrotic syndrome. These diseases are usually ruled out with standard clinical tests. Patients with hepatic hydrothorax should be treated with fluid restriction and diuretics. Patients with severe symptoms due to refractory hepatic hydrothorax might benefit from pleural sclerosis and surgical closure of diaphragmatic defects.     

CT平扫对结核性腹膜炎的诊断价值

目的 探讨结核性腹膜炎的CT平扫表现特征。方法 回顾性分析46例有CT扫描资料的结核性腹膜炎患者,其中经手术病理证实6例,腹腔穿刺证实2例,腹腔镜检证实4例,试验性治疗诊断34例。观察内容包括结核性腹膜炎累及壁腹膜、大网膜、肠系膜及腹膜后间隙的CT表现特征。结果 （1）壁腹膜增厚33例,其中均匀、光滑增厚27例,局部不规则增厚6例;（2）腹腔积液31例,其中20例为少量积液;（3）大网膜增厚26例,表现为污迹样增厚22例,饼状增厚2例;（4）肠系膜受累32例,其中9例合并小结节影：（5）淋巴结增大16例;（6）肠壁增厚1例,肠间距增宽2例。结论 结核性腹膜炎CT平扫的主要表现有少量腹腔积液、均匀性腹膜增厚、大网膜污迹样增厚,以及肠系膜、肠管受累与腹腔淋巴结增大,CT平扫能为结核性腹膜炎的诊断提供重要信息。     

Needle biopsy of the peritoneum

Summary Twenty-one peritoneum needle biopsies were performed in 17 patients. Proper samples for microscopic examination were obtained in 18 instances, 9 of which were diagnostic. In 6 patients with tuberculosis of the peritoneum, 5 biopsies revealed characteristic granulomas. Of 8 patients with intra-abdominal carcinoma and ascites, the biopsy in 3 revealed metastases; in 2, the diagnosis was obtained through cytologic study of the ascitic fluid; in 2 of the other 3 patients, no indication of metastases of the peritoneum was found at autopsy.The results obtained by other authors and ourselves suggest that this is a useful method which should be performed in instances of ascites of unknown etiology, suspected tuberculosis, or neoplasia.The authors are grateful to Dr. Uriel García C áceres, Department of Pathology, Faculty of Medicine Cayetano Heredia, Lima, Peru.     

Lymphocyte and erythrocyte turnover in thoracic duct lymph in patients with schistosomal hepatosplenomegaly and portal hypertension

In 60 patients with hepatosplenic schistosomiasis and portal hypertension and in 20 control subjects, the turnover of erythrocytes and lymphocytes circulating in thoracic duct lymph was compared. Despite slight anemia in most patients with schistosomiasis, there was a greatly accelerated extravascular splanchnic circulation rate of erythrocytes. Lymphocytes also circulated more rapidly, but in contrast to erythrocytes, the peripheral blood lymphocyte count was elevated in schistosomal patients. Although thoracic duct lymph flow was increased at all stages of schistosomiasis, it was less rapid in "ascitic" and "varix bleeders" and thus the extravascular circulation turnover of erythrocytes and lymphocytes appeared to decline with chronicity of disease. The more rapid lymphocyte and erythrocyte "turnover," however, was almost entirely due to increased formation of interstitial fluid (greater lymph flow) suggesting that a prime regulator of splanchnic cellular migration was "solvent drag." These findings may derive from deranged portal microvascular dynamics (e.g., increased microvascular pressure, collagen deposition in Disse's space, capillarization of hepatic sinusoids, presinusoidal obstruction) as well as generalized host immunoresponsiveness to schistosomal infection.     

Biopsy of the Peritoneum in Decompensated Cirrhosis of the Liver

Fifteen patients with noninfectious chronic ascites due to liver cirrhosis were investigated by laparoscopy and/or peritoneal biopsy. Laparoscopie inspection revealed thickening of the peritoneum, diffuse patchy redness and diffusely increased small vascular injection. Biopsies of the parietal peritoneum showed cuboidal transformation and hyperplasia of the mesothelial cells, fibrinoid depositions, fibroblastic proliferation and mononuclear cell infiltration. Probable pathogenesis of the parietal chronic nonspecific peritonitis in ascites of liver cirrhosis is the presence of irritating substances in the ascitic fluid. Diffuse small vascular injection of the peritoneum reflects most likely the inflammatory nature of the peritoneal process and not a direct influence of portal hypertension.     

Role of atrial natriuretic factor in sodium and water retention in patients with schistosomal hepatic fibrosis.

Fifty subjects divided into three groups were studied: Group I: 10 normal adult subjects as controls. Group II: 20 patients with schistosomal hepatic fibrosis (SHF) without ascites (compensated stage). Group III: 20 patients with SHF with ascites. In all these patients plasma atrial natriuretic factor (ANF), serum aldosterone and serum osmolality were determined. There was a significant decrease in the plasma ANF in groups II and III compared to group I. There was a significant increase in the serum aldosterone level in group III compared to groups I and II. No significant difference was noted in serum sodium and potassium levels among the three groups. There was a significant decrease in serum osmolality in groups II and III compared to group I.     

Hemorrhagic ascites: are we missing endometriosis?

Peritoneal tuberculosis, carcinomatosis and pancreatic ascites are often considered as differential diagnosis of hemorrhagic ascites. Endometriosis can rarely present as hemorrhagic ascites and closely mimic these conditions. When this occurs without common clinical features of endometriosis, it can create a diagnostic challenge to the treating physician. We present three patients with endometriosis who presented with hemorrhagic ascites; two of them did not have gynecological symptoms or significant pelvic disease. These patients were evaluated several times in many centers and even received multiple courses of anti-tuberculous treatment. The diagnosis was made by histologic examination of parietal peritoneum obtained by laparoscopy or laparotomy. The diagnosis was missed possibly because of the atypical presentation, lack of clinical suspicion and incomplete assessment. In conclusion, this potentially treatable condition should be considered as a differential diagnosis for hemorrhagic ascites in a premenopausal woman.     

Advantages of cytodiagnostics in ascites (author's transl)

Investigations were made on 253 patients. In 44 patients with peritoneal carcinosis, cell imprints and histological investigations of tissues from the changes in the peritoneum, taken during laparoscopy have been performed. In 122 out of 151 patients with neoplastically stipulated ascites (80.8 per cent) tumour cells have been found in the ascitic fluid. The false negative results represented 19.8 per cent and the false positive results--2.0 per cent. In all cell imprints from peritoneal tissues tumour cells have been detected even when these were absent in the ascitic fluid. In 2 out of 49 patients (4 per cent) the histological investigation of bioptic material from the peritoneum showed no neoplastic changes. The activity of gamma-glutamyltransferase and alkaline phosphatase in the ascitic fluid of patients with carcinosis was higher than in the remaining patients, whilst the 5'-nucleotidase did not show particular deviations. The cytologic method was well tolerated by the patients and showed higher specificity, sensitiveness, simplicity and realization and in 80.8 per cent solved the diagnostic problems and made useless the application of other labour-consuming, burdensome and more expensive methods of investigation.     

Peritoneal ovarian metastases simulating liver parenchymal metastases.

Ovarian carcinoma frequently metastasizes to the peritoneum, both locally in the pelvis and elsewhere. Computed tomography (CT) has a limited ability to identify peritoneal implants with a diameter of 2 cm or less. Three cases of subphrenic, diaphragmatic peritoneal implants, preoperatively at CT thought to represent liver parenchymal metastases, are presented. The difficulty in the differentiation of diaphragmatic peritoneal implants from metastases to the capsule and parenchyma of the liver is discussed. To achieve a radical liver resection in patients with ovarian carcinoma, metastatic peritoneal implants must be excluded during operation.     

经自然腔道内镜手术检查诊断结核性腹膜炎20例

目的探讨经胃的经自然腔道内镜手术（NOTES）腹腔内镜检查对结核性腹膜炎的诊断价值。方法回顾20例经胃NOTES腹腔内镜检查及病理活检确诊为结核性腹膜炎患者的相关临床资料,并进行性分析总结。结果20例患者经胃NOETS腹腔内镜检查及病理活检后明确诊断为结核性腹膜炎。内镜检查结果为4型：（1）粟粒型：内镜表现为腹水、腹膜散在分布白色粟粒状结节;（2）粘连型：内镜表现腹膜增厚,腹膜与网膜、肠管之间存在不同程度的粘连;（3）干酪型：内镜表现壁层溃疡及淡黄色于酪样物质;（4）混合型：内镜表现为同时存在2种或3种类型。其他各项实验室及特殊检查的阳性例数分别为血红蛋白下降10例,红细胞沉降率增快16例,C反应蛋白升高13例,CA125升高18例,胸片异常8例,腹部彩超异常2例,腹部CT异常7例,结核菌素实验阳性9例,结肠镜检查阳性1例,20例结核抗体、腹水培养、腹水细菌学检查、胃镜检查均阴性。结论经胃NOTES腹腔内镜检查及病理活检是确诊结核性腹膜炎非常有效的诊断方法。