Primary gastrointestinal cancers presenting as gynecologic malignancies

OBJECTIVE: The goal of this study was to characterize presenting symptoms, prognostic factors, and treatment outcome in patients diagnosed with primary gastrointestinal (GI) cancers initially presumed to be of gynecologic origin. METHODS: A retrospective review of all admissions to the gynecologic oncology service at Saint Luke's Hospital in Kansas City, Missouri, was performed between 1993 and 2003. Twenty-six patients with primary GI cancers who presented with presumed gynecologic malignancies were identified. Clinical and pathologic features were reviewed, methods of diagnosis were recorded, and survival was analyzed by the Kaplan-Meier method. RESULTS: One percent of all gynecologic cancer referrals had a tumor of nongynecologic gastrointestinal origin. Seven subtypes of GI cancers were identified, most at stage 4 disease. Colon cancer was identified most commonly (26.9%). Abdominal pain was the most frequent symptom (57.6%), and an adnexal mass was diagnosed in the majority of patients (65.4%). Preoperative endoscopic evaluation provided a definitive diagnosis in only 3.8%. The median survival was 15 months with a 5-year survival of 35%. Ninety-six percent of patients had their GI tumor definitively diagnosed by exploratory laparotomy. Optimal cytoreduction provided a 7-month survival advantage. CONCLUSION: Most patients required a major surgical procedure to establish the primary diagnosis of gastrointestinal cancer. The cancers encountered were almost always at advanced stage disease and were referred to the gynecologic oncologist due to the presence of an adnexal mass and a failed preoperative work-up. Surgical management should include removal of the primary or recurrent GI tumor and cytoreduction of all bulky disease, including adnexal metastases.     

Treatment of massive gastrointestinal hemorrhage from aortoenteric fistula.

Massive hemorrhage of the upper part of the gastrointestinal tract presents a formidable crisis in surgical management. The preoperative diagnosis should be suspected in patients with a vascular prosthesis or primary abdominal aortic aneurysm. The characteristic signs and symptoms represent the triad of a pulsatile mass in the upper part of the abdomen, intermittent hemorrhage in the upper part of the gastrointestinal tract and severe epigastralgia not relieved by antacids. No ideal operative technique has evolved for correcting the abnormal physiopathologic condition. Our recent experience with three patients highlights the problems of unremitting sepsis and recurrent fistulization.     

An endometriotic vault fistula presenting with monthly bleeding after hysterectomy

Introduction  

The aetiology of endometriosis remains unknown. The clinical presentation of endometriosis can be highly variable, occurring in numerous potential locations outside the abdomen and associated with distinct complaints. Recurrence is common, though we present a very rare case of recurrence and complication.     

子宫动静脉瘘致阴道大出血的临床分析

目的探讨子宫动静脉瘘致阴道大出血患者的临床特点、诊断与治疗方法以及预后。方法对我院1990年8月至2003年5月收治的15例子宫动静脉瘘患者的临床资料进行回顾性分析。结果本组患者都以异常阴道大量出血就诊,15例均合并剖宫产分娩史、多次刮宫史或妇科恶性肿瘤病史。彩色B超及选择性子宫动脉造影通常可以明确诊断。诊断性刮宫并不能起到有效治疗作用,反而会加重出血。15例患者中,14例接受子宫动脉栓塞术,其中11例(79％)栓塞治疗成功,栓塞术后无并发症发生。保守治疗成功的患者术后均能恢复正常月经,并有5例成功妊娠。结论子宫动静脉瘘是导致阴道大出血的少见却严重的原因之一,子宫动脉栓塞术是治疗子宫动静脉瘘出血有效的保守治疗方法,栓塞术后患者的子宫及卵巢功能并不受影响。     

Primary endodermal sinus tumor of the endometrium presenting as "recurrent" endometrial adenocarcinoma

BACKGROUND: Primary endodermal sinus tumor of the endometrium is an extremely rare malignancy with few reports in the world literature. CASE: A case of primary endodermal sinus tumor of the endometrium is presented. The case is unusual in several aspects: it occurred in a patient with a history of breast cancer and long-standing tamoxifen use, and was diagnosed only after presenting as an apparent unexpected recurrence of endometrial adenocarcinoma. The tumor recurred despite initial cytoreductive surgery and combination chemotherapy. CONCLUSION: Rare types of endometrial cancers may present as unexpected recurrences of previously resected endometrial adenocarcinomas. Appropriate therapy depends on obtaining sufficient tissue to establish an accurate diagnosis to ensure selection of proper chemotherapeutic agents.     

Extensive genitourinary tuberculosis presenting as spontaneous vesico-vaginal fistula

We report a case of extensive genitourinary tuberculosis presenting as spontaneous vesico-vaginal fistula.     

Lymphogranuloma venereum presenting as a rectovaginal fistula.

Lymphogranuloma venereum (LGV) is a rare form of the sexually transmitted disease caused by Chlamydia trachomatis. In the United States, there are fewer than 350 cases per year. In a review of the world's literature, there has not been a case reported in the last thirty years of a case of LGV presenting as a rectovaginal fistula. We present a case of an otherwise healthy American woman who presented with a rectovaginal fistula. Although uncommon, LGV does occur in developed countries and may have devastating tissue destruction if not recognized and treated before the tertiary stage.     

An unusual case of complete duodenal obstruction with massive stomach dilatation caused by recurrent cervical cancer

Presented is a case of squamous cell cancer of the uterine cervix with metastatic paraaortic disease, 9 years following treatment. An unusual complete duodenal obstruction accompanied by massive stomach dilatation from the metastases is described.     

Secondary infection presenting as recurrent pulmonary hypertension.

Primary infection in the neonate, especially group B streptococcal infection, has long been recognized as a cause of persistent pulmonary hypertension of the newborn (PPHN), sometimes requiring treatment with inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO). However, secondary nosocomial infections in the neonatal period have not been widely reported as a cause of severe recurrent pulmonary hypertension (PHTN). We now present two cases of secondary infection in the neonate leading to significant PHTN. In both cases, the infants presented with PPHN soon after birth, requiring transfer to a level 3 neonatal intensive care unit and treatment with high-frequency oscillatory ventilation and iNO. After successful resolution of the initial PPHN, including extubation to nasal cannula, both infants developed signs of severe recurrent PHTN, leading to reintubation, high-frequency oscillatory ventilation and iNO therapy, and consideration of ECMO. In both cases, blood cultures taken at the time of recurrence of PHTN returned positive, one for Staphylococcus epidermidis, the other for methicillin-resistant Staphylococcus aureus. These unusual cases present the possibility of severe recurrent PHTN requiring iNO or ECMO in the setting of secondary infection. We speculate that these infants, although extubated after their first episodes of PHTN, were at risk for recurrence of PHTN due to continued pulmonary vascular reactivity.     

Systematic assessment of massive bleeding of the lower part of the gastrointestinal tract.

A study of 83 patients admitted with massive bleeding in the lower part of the gastrointestinal tract is presented using a diagnostic approach primarily of angiography and colonoscopy with the adjunctive investigations of scintigraphy, small intestine series and computed tomographic scan. The source of bleeding was identified preoperatively in 74 patients. Nine patients had a diagnostic laparotomy and the cause was found in an additional seven. A source was not identified in two patients at exploration and a blind resection was not performed. The two patients have not had recurrent bleeding four and nine years postlaparotomy. The sites of bleeding were colon in 44 patients, small intestine in 24 and the anorectum in 11. Sixty-five patients were treated operatively, two by angiographic embolization and two by endoscopic electrocoagulation. Fourteen patients were managed conservatively. The mortality rate was 10.8 percent and five patients rebled after treatment. We conclude that a thorough systematic assessment of patients with bleeding in the lower part of the gastrointestinal tract is important to localize the site of the hemorrhage. Exploratory laparotomy is the final diagnostic modality, and if a source has not been identified, a blind colonic resection should not be performed.     

A case of pelvic actinomycosis presenting as cutaneous fistula

Actinomycosis of the female genital tract has greatly increased over the last two decades. A pelvic form of the disease, associated with the use of Intra-uterine Devices (IUD), can severely damage pelvic organs and even can lead to death. We report a case of pelvic actinomycosis presenting as cutaneous fistula.     

Plasma cell myeloma presenting as abnormal uterine bleeding.

We report a case of a 53-year-old woman who presented with anemia and abnormal uterine bleeding. Endometrial and cervical biopsies revealed infiltration by large atypical cells, which were characterized as neoplastic plasma cells. Further investigations revealed systemic plasma cell dyscrasia (i.e., plasma cell myeloma). We therefore report a case of plasma cell myeloma, initially presenting as abnormal uterine bleeding.     

Use of recombinant factor VIIa for the control of massive bleeding caused by uterine hypotonia in post-placental period

We report our clinical opinion for recombinant activated factor VII (NovoSeven, Novo Nordisk, Copenhagen, Denmark) administration in puerperae with massive haemorrhage caused by uterine hypotonia. Four women with severe bleeding in post-placental period received NovoSeven in bolus IV. The blood loss and laboratory changes in hematology and haemostasis parameters are monitored. The right time of application and the mean effective dose of the medication are discussed. The bleeding was ceased in all cases. Decrease in values of Hb, Er and PTT was noted. The mean administered dose of 72 micrograms/kg BW was effective. The laboratory values showed tendency for improvement on the 24 hour after administration and normal levels on discharge. The use of recombinant factor VIIA in puerperae with severe bleeding in the postplacental period is effective and safe enough and could be an alternative to the extreme surgical procedures.     

Abnormal vaginal bleeding in adolescence as the presenting symptom of a bleeding diathesis.

Menorrhagia in adolescents may be the presenting sign of a systemic hemostatic disorder. The evaluation of adolescents with menorrhagia should include an assessment of the pelvic organs to exclude anatomic pathology, and if none is found the possibility of primary hematological abnormality should be considered. Initially, a thorough personal and family history of a bleeding tendency should be obtained. Thereafter, we suggest a number of basic "screening" clotting assays be performed. These should include a platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen level and bleeding time. Abnormalities of any of these tests should then be further investigated using more specific clotting assays. The most common disorders reported to cause menorrhagia in adolescents are von Willebrand's disease, factor XI deficiency, and Glanzmann's thrombasthenia. General and specific therapeutic measures for treating these disorders are discussed.