Spontaneous regression of prolactin-producing pituitary adenomas

Two women evaluated for amenorrhea, galactorrhea, and hyperprolactinemia had radiographic changes of the sella turcica (localized erosion on trispiral tomography) suggestive of a pituitary tumor. Both patients experienced spontaneous regression of apparent prolactin-secreting adenomas with a marked decrease in the quantity of galactorrhea and a reduction of serum prolactin concentrations to the normal range. One patient noted a marked improvement of headaches and spontaneous menses resumed in the other patient.     

Diagnosis of prolactin-secreting pituitary microadenoma.

Four women with secondary amenorrhea associated with hyperprolactinemia were studied. Baseline hormonal evaluation, including serum FSH, serum LH, TSH, T3, T4, and plasma cortisols were normal. Plain sella turcia x-rays were also normal. Prolactin-secreting pituitary microadenomas were found in all of the patients only after further diagnostic studies were done. These studies included polytomography of the sella turcia, dynamic pituitary testing of growth hormone reserve, ACTH reserve, gonadotropin reserve, and prolactin suppression with L-dopa. The early diagnosis of a small prolactin-secreting adenoma may be possible if several diagnostic criteria are ulilized. The most sensitive techniques available are: (1) polytomography, (2) the magnitude of plasma prolactin evaluation, and (3) the failure of suppression of prolactin secretion with L-dopa. Our findings emphasize the importance of an extensive evaluation of all women with amenorrhea associated with hyperprolactinemia.     

The natural history of postoperative venous thromboemboli in gynecologic oncology: a prospective study of 382 patients

Three hundred eighty-two patients who underwent major operations for gynecologic malignancy were studied prospectively to determine the natural history of postoperative venous thromboemboli. Iodine 125-labeled fibrinogen leg counting, to diagnose deep venous thrombosis, was performed daily. Sixty-three patients (17%) developed postoperative venous thromboembolic complications. Deep venous thrombosis initially arose in the calf veins in 52 patients. Twenty-seven percent of these thrombi lysed spontaneously. Four percent of thrombi in the calf veins progressed to deep venous thrombosis in the femoral vein, and 4% resulted in pulmonary emboli. Nine other patients developed proximal deep venous thrombosis without prior thrombosis in the calf veins. One patient with proximal deep venous thrombosis also had a pulmonary embolus. Two patients with no evidence of deep venous thrombosis on prospective 125I-labeled fibrinogen leg counting developed pulmonary emboli, including one fatal pulmonary embolus that was found at autopsy to have arisen from the internal iliac veins. Fifty percent of all venous thromboemboli were detected within 48 hours of operation, although two patients developed significant deep venous thrombosis and pulmonary emboli after discharge from the hospital. These results add important information to our understanding of this disease process, and raise issues related to appropriate treatment and prophylaxis of venous thromboembolism in patients after gynecologic operations.     

A VP16-213- and cisplatin-containing regimen for treatment of refractory ovarian germ cell malignancies

Chemotherapy with VP16-213 and cisplatin was administered to three patients with ovarian germ cell malignancies resistant to chemotherapy with methotrexate, actinomycin D, and chlorambucil and with vinblastine, bleomycin, and cisplatin. Remission was achieved in all patients and has been sustained for 9 to 50 months. Use of these agents in a salvage regimen for resistant germ cell malignancies is recommended.     

Rh isoimmunization: A 24 year experience at Duke University Medical Center

A retrospective analysis was made of Rh-sensitized patients delivered of their babies at Duke University Medical Center during a 24 year period. Records of 202 obstetric patients representing 280 sensitized pregnancies from a pool of 39,910 deliveries were analyzed for past obstetric history, blood group information, antibody determinations, amniocentesis data, and details of the pregnancy and delivery. The medical records of the corresponding infants were analyzed for their neonatal course. A severity index (SI) was devised to classify the degree of severity of the erythroblastosis fetalis. A significant correlation between SI and the ΔOD₄₅₀ of amniotic fluid, umbilical cord hematocrit, and bilirubin was noted. The evaluation of amniotic fluid ΔOD₄₅₀ is considered to be the cornerstone of clinical management. Twenty-nine patients had initial Liley zone 1 determinations which decreased to ΔOD₄₅₀ = 0.000; however, only 10 of 29 (34.5%) of the infants were unaffected, and 13 of 29 (44.8%) had mild sensitization, four of 29 (13.8%) had moderate sensitization, and two of 29 (6.9%) had severe sensitization. The previously held concept of “critical titer” as a guide for initiating amniocentesis is challenged, and the recommendation is made that amniocentesis for amniotic fluid determination should be undertaken in any patient with a positive indirect Coombs titer.     

Vitamin-B12 deficiency following therapy in gynecologic oncology

Vitamin-B₁₂ deficiency results from inadequate absorption of the vitamin by the distal ileum and depletion of available stores. Both radiotherapy and intestinal resection can contribute to development of this condition. The significance of this problem in gynecologic oncology is discussed and two patients are described.     

Serial nephelometric urine IgG measurement and the management of pregnancy-induced hypertension

Serial IgG analysis was performed on the urine and serum of 16 patients with pregnancy-induced hypertension. Significant immunoglobulinuria developed prior to the development of azotemia, significantly decreased creatinine clearance, significant proteinuria (greater than or equal to 3+ dipstick or greater than or equal to 5 gm per 24-hour urine collection), or oliguria. Nephelometric measurement of urine IgG concentrations appears to be a rapid and accurate method for confirming the severity of clinical disease, the degree of renal involvement, the benefit of treatment modalities on renal function, and the likelihood of postpartum maternal morbidity.     

Pseudoobstruction of the colon complicating choriocarcinoma

Colonic pseudoobstruction is an enigmatic condition which can mimic mechanical obstruction clinically and lead to spontaneous cecal perforation. A patient who was treated for choriocarcinoma developed colonic pseudoobstruction and appropriate evaluation permitted nonsurgical management. The etiologies, diagnosis, and management of colonic pseudoobstruction are discussed.     

Human chorionic gonadotropin levels in complete and partial hydatidiform moles and in nonmolar abortuses

The rates of regression of human chorionic gonadotropin (hCG) in patients with complete hydatidiform moles, partial hydatidiform moles, and nonmolar abortions were compared. No difference in rates of regression was found among the three groups, but levels of hCG immediately after uterine evacuation were significantly higher in the group with complete hydatidiform moles. Differences in the time required for hCG levels to become undetectable were attributed to the difference in the degree of initial elevation of hCG.     

A contemporary approach to suspected ectopic pregnancy with use of quantitative and qualitative assays for the beta-subunit of human chorionic gonadotropin and sonography

Although assays for the beta-subunit of human chorionic gonadotropin (beta-hCG) and ultrasonography have become popular diagnostic aids in the approach to patients with a suspected ectopic pregnancy, their true utility has not been clearly defined; in fact, the beta-hCG assay is so sensitive that proper clinical interpretation is sometimes difficult. A recent study describing a "discriminatory zone" (beta-hCG level of 6000 to 6500 mIU/ml), which correlates beta-hCG levels with appearance of a gestational sac on ultrasound scans, has been reported to be of diagnostic benefit. A prospective study of 103 women with suspected ectopic pregnancy was undertaken utilizing an algorithm which included beta-hCG assays (quantitative as well as qualitative) and ultrasonography. Seventy-three patients were found not to be pregnant, and seven had a normal pregnancy, 14 patients ultimately had a spontaneous abortion, and seven ectopic pregnancies were identified. The following conclusions were drawn: (1) a qualitative beta-hCG assay with a sensitivity of 25 mIU/ml is an effective test in screening for ectopic pregnancies; (2) the concept of a "discriminatory zone" is valid but not of frequent clinical utility, since most patients suspected of having an ectopic gestation have beta-hCG levels below this zone; (3) serial monitoring of beta-hCG values is an important diagnostic aid; (4) culdocentesis is still an important contemporary diagnostic test for the patient suspected of ectopic pregnancy.     

Surgical complexity score and role of laparoscopy in women with advanced ovarian cancer treated with neoadjuvant chemotherapy

ObjectivesTo evaluate surgical complexity scores (SCS) and minimally invasive surgery (MIS) at interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) patients receiving neoadjuvant chemotherapy (NACT).MethodsA multi-institutional study of NACT with IDS for advanced EOC was conducted. Demographic data were abstracted and SCS assigned based on IDS findings. Disease-specific overall survival (DSS) was defined as the time from completion of adjuvant chemotherapy to death due to disease. Cox proportional hazards regression models were used for univariate and multivariate survival analyses.Results282 patients were identified; 80.5% had high-grade serous histology and 54.6% were <75 (median 63.9; range 34.1–84.8). Approximately 84% were optimally cytoreduced (61% R0; 23% <1 cm). In multivariate analyses, age 75+ (p ≤ 0.001), residual disease (>1 cm; p = 0.03), and SCS ≥ 3 (p = 0.04) were significantly predictive of worse DSS when morbidity and ASA score were also in the model. When optimally debulked was defined as R0, only age 75+ (<0.001) was significantly associated with decreased DSS. In the R0 cohort, SCS did not significantly predict DSS. However, subset analysis defining optimal ≤1 cm, revealed higher SCS was associated with a 1.6-fold increased risk of death (p = 0.02).Fifty-one patients underwent laparoscopic IDS. Twenty-four (47%) were converted to laparotomy to achieve optimal debulking in 21 patients (87.5%); while 25 had laparoscopic optimal cytoreduction (19/25 [76%] R0).ConclusionsIn women with advanced EOC treated with NACT, older age, SCS ≥ 3, and residual disease >1 cm at IDS were predictors of worse survival. MIS appears safe and feasible with acceptable optimal cytoreduction rates.     

Renal metastases of malignant gestational trophoblastic disease: The use of intravenous urography in staging

Intravenous urography (IVU) was performed in 289 patients at the time of diagnosis of malignant gestational trophoblastic disease (GTD). Ninety-five percent of these studies were normal, and none of the urologic abnormalities detected provoked alteration of the patients' tumor-related therapy. In the detection of renal metastases, false-positive and false-negative intravenous urograms were encountered. It is concluded that IVU lacks sufficient sensitivity and specificity in the detection of renal metastatic GTD; alternate screening methods are recommended.     

Spring clip sterilization: one-year follow-up of 1,079 cases.

This is a report of 1,079 patients who underwent laparoscopic clip sterlization as of March, 1974. A one-year follow-up was obtained on 977 patients, or 90.5 per cent. Complications due to the clip technique appear limited to postoperative cramps for 24 to 48 hours in 26 per cent of patients. No ectopic pregnancies were detected. Pregnancies, when corrected for unsuspected existing pregnancies and surgical and manufacturing errors, occurred in 2 to 6 cases, for a method failure rate of 2 to 6/1,000. This report documents that experienced laparoscopists can perform this practice with local anesthesia, in combination with first-trimester abortion, and in hospital facilities other than an operating room.     

The occurrence of adenocarcinoma in endometriosis of the rectovaginal septum during progestational therapy.

A patient is presented who developed adenocarcinoma in endometriosis of the rectovaginal septum during a second course of hormonal therapy. Malignant transformation in an area of endometriosis during sex steroid therapy has not been previously reported. The rectovaginal septum is recognized as probably the most common site of malignant transformation in extraovarian foci of endometriosis.     

Integrity of central dopaminergic system in women with postpartum hyperprolactinemia

In order to elucidate the role of elevated prolactin (PRL) on the central dopaminergic systems, the suppressive effects of PRL were studied after the administration of l-dopa and l-dopa plus carbidopa on consecutive days to the following three groups: 10 normoprolactinemic subjects, six nonnursing normal puerperal women, and seven hyperprolactinemic women without any evidence of pituitary tumor. In the normoprolactinemic subjects (basal PRL 13 ± 2 ng/ml mean ± SE), the suppressive effects of l-dopa alone and l-dopa plus carbidopa were similar (48% ± 4% and 58% ± 6%, respectively). In puerperal hyperprolactinemic subjects, the basal PRL (116.8 ± 16.4 ng/ml) was suppressed 77% ± 2% after administration of l-dopa and 51% ± 7% after l-dopa plus carbidopa, significantly different from that of l-dopa alone (p < 0.005), but similar to that observed in normal subjects. In the patients with idiopathic hyperprolactinemia, the baseline PRL (131 ± 38 ng/ml) decreased 56.3% after the administration of l-dopa. In the presence of peripheral dopa decarboxylase inhibition, the administration of l-dopa decreased plasma PRL values 30%, a drop significantly different from that of l-dopa alone (p < 0.02). Women with idiopathic hyperprolactinemia exhibit reduced central dopaminergic inhibition of PRL secretion similar to that in patients with pituitary tumor; whereas the response to central dopaminergic inhibition in postpartum women with comparable baseline PRL levels is similar to that in normoprolactinemic subjects. This indicates that hyperprolactinemia per se is not associated with a state of reduced central dopaminergic inhibition. The increased pituitary sensitivity to l-dopa observed in puerperal women may be due to alterations in PRL receptors or vascularity.     

Vascular plasminogen activator levels and thromboembolic disease in patients with gynecologic malignancies

Vascular plasminogen activator levels were measured preoperatively in 66 women with gynecologic malignancies. These levels were compared to levels in a matched control group of 84 women and to the incidence of postoperative venous thromboembolic disease in the patient group. Significantly lower levels of plasminogen activator were measured in patients who developed thrombotic complications (p = 0.0014). When results were stratified according to tumor location, patients with ovarian carcinoma had significantly higher activator levels than those found in control subjects (p = 0.0072), and significantly lower levels were associated with endometrial malignancy (p = 0.0140). Measurement of releasable plasminogen activator before operation may be an effective, noninvasive means of identifying patients potentially at risk for venous thromboembolic disease. Postoperative measurement of plasminogen activator may eventually find a role in monitoring tumor therapy and recurrence.