Liver presentation: Report of two cases

Two cases of liver presentation are described, illustrating the need for care in the diagnosis of central placenta previa in the last trimester of pregnancy. Cesarean section in most clinics is the accepted treatment for the central variety of placenta previa. Gross fetal abnormalities which are not demonstrable by roentgenography may produce the clinical picture and vaginal findings of central previa and should be considered in the differential diagnosis.     

Report of two cases of controlateral groin recurrence after ipsilateral groin node dissection for vulval cancer

Among the more conservative management strategies intended to individualize the surgical treatment of vulval cancer, ispilateral groin dissection is proposed for T1-T2 lateral lesions. Since patients found negative for metastatic nodes in the ipsilateral groin and developing unexpected recurrences in the controlateral non-dissected groin have a poor outcome, it is useful to report such cases to better evaluate the safety of these less aggressive surgical procedures.     

The utility of sentinel lymph node mapping in the management of endometrial atypical hyperplasia

Objectives

To determine the risk of endometrial cancer (EC) and lymph node involvement in patients with a preoperative diagnosis of “AH-only” versus “AH - cannot rule out carcinoma” and to study the value of SLN mapping.

Laparoscopic pelvic and paraaortic lymph node dissection: analysis of the first 100 cases

OBJECTIVE: The aim of this study was to analyze the first 100 cases of planned laparoscopic pelvic and paraaortic lymph node dissection (LND) done for staging of gynecologic cancers. The goal of the study was to assess prognostic factors for conversion to laparotomy and document complications. METHODS: A retrospective review of patients who had planned laparoscopic bilateral pelvic and bilateral paraaortic LND for staging of their gynecologic cancer was performed. Patients were identified by our institutional database and data were collected by review of their medical records. Data were obtained regarding demographics, stage, histology, length of stay, and procedural information including completion rates, operating room time, estimated blood loss, assistant, lymph node count, and complications. Associations between variables were analyzed using Student t tests, analysis of variance, and chi(2) testing (Excel v7.0). RESULTS: A total of 103 patients were identified from 12/15/95 to 8/28/00. Demographics included mean age of 66.2 (25-92) and mean Quetelet index (QI) of 30.8 (15.9-56.1). A total of 34/103 (33.0%) had > or =1 previous laparotomy. Ninety-five patients had endometrial cancer and 8 had ovarian cancer. Eighty-six of 103 (83.5%) were stage I or II. The length of stay was shorter for those who had laparoscopy than for those who needed conversion to laparotomy (2.8 vs 5.6 days, P < 0.0001). Laparoscopy was completed in 73/103 (70.9%) of the cases. Completion rates were 62/76 (81.6%) with QI < 35 vs 11/27 (40.7%) with QI > or = 35, P < 0.001. Significantly more patients had their laparoscopy completed when an attending gynecologic oncologist was the first assistant compared to a fellow or a community obstetrician/gynecologist (92.9%, 69.0%, 64.5%, P < 0.0001). The top three reasons for conversion to laparotomy were obesity, 12/30 (29.1%), adhesions, 5/30 (16.7%), and intraperitoneal disease, 5/30 (16.7%). Pelvic, common iliac, and paraaortic lymph node counts did not differ when compared to those of patients who had conversion to laparotomy (18.1, 5.1, 6.8 vs 17.3, 5.7, 6.8, P = ns). Complications included 2 urinary tract injuries, 2 pulmonary embolisms, and 6 wound infections (all in the laparotomy group). Two deaths occurred, 1 due to a vascular injury on initial trocar insertion and 1 due to a pulmonary embolism after a laparotomy for bowel herniation through a trocar incision. CONCLUSION: Laparoscopic bilateral pelvic and paraaortic LND can be completed successfully in 70.9% of patients. Age, obesity, previous surgery, and the need to perform this procedure in the community were not contraindications. Advantages include a shorter hospital stay, similar nodal counts, and acceptable complications.     

Microglandular endocervical hyperplasia and endocervical adenocacinoma in pregnant--description of two cases

Two clinically identical cases of young, pregnant women, presented with exocervical polypoid masses are described. Because of beginning delivery in both cases, the diagnoses are made on frozen sections. In the first case histological examination reveals microglandular endocervical hyperplasia. A successful delivery by caesarian section and no more operations is performed. In the second case, an endocervical adenocarcinoma is diagnosed and after a successful delivery by caesarian section, a laparohysterectomy with bilateral adnexectomy and lymph node dissection is performed. Detailed histological examination of the endocervical neoplasm discloses a well differentiated papillary villoglandular adenocarcinoma, containing minor elements of more aggressive serous carcinoma, which may adversely affect the outcome. Three consequent recurrences are found in this patient for a period of 5 years and 3 months after the operation.     

Blue nevus of the endocervix: Report of two cases and ultrastructure

Two cases of blue nevus of the endocervix are reported and the electron microscopic findings from one of them are discussed as related to their fine structural organization and possible histogenetic origin and development. Blue nevus cells of the endocervical mucosa are engaged in melanogenesis in all respects similar to that observed in blue nevus cells of the dermis and are regarded as their visceral counterparts. Their ultra-structural resemblance and close location to perineurial fibroblasts of nonmyelinated nerve bundles seem to suggest that at least in some instances the perineurial fibroblasts may be the most immediate neural crest precursors of blue nevus cells of the endocervix.     

Axillary lymph node dissection in the case of sentinel lymph node micrometastatic invasion: evaluation of three predictive models

Objective

To evaluate three predictive risk models of non-sentinel lymph node (NSLN) involvement in the case of micrometastatic sentinel node (SLN) involvement for breast cancer.

Study design

This retrospective study included 72 successive patients with micrometastatic SLN involvement who had surgery between March 1996 and October 2007. All patients had undergone immediate or delayed axillary lymph node dissection (ALND). The Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram, the Stanford nomogram and the Tenon score were applied to the population to calculate the probability of NSLN involvement.

Results

For the MSKCC nomogram with a threshold value of 10%, sensitivity was 50%, specificity was 70% and the negative predictive value (NPV) was 89%. The area under the receiver operating characteristic curve (AUC) was 0.6 (significant). Use of this nomogram would have avoided ALND in 49 out of 72 (68%) patients, but five out of 10 (50%) patients with NSLN involvement would not have been detected. With a threshold value of 7%, the AUC was 0.69, sensitivity was 90% and NPV was 97%. ALND would have been avoided in 31 out of 72 (43%) patients, with a 3% chance of leaving metastases when abstaining from ALND. For the Tenon score with a threshold value of 3.5, sensitivity was 50%, specificity was 72% and the AUC was 0.62. This was not clinically applicable because eight out of 10 (80%) patients with NSLN involvement would not have been detected. For the Stanford nomogram, the results could not be interpreted because the AUC was not significant.

Conclusion

None of the tested models are sufficiently reliable for use in daily practice. The MSKCC nomogram showed the most encouraging results, especially for a threshold value of 7%, but this has not been validated in the literature. Complete axillary dissection should be performed in the case of micrometastatic SLN involvement until more data become available.     

Simultaneous vulvar intraepithelial neoplasia and Paget's disease: Report of two cases

Abstract. Orlandi A, Piccione E, Francesconi A, Spagnoli LG. Simultaneous vulvar intraepithelial neoplasia and Paget's disease: Report of two cases.
We describe a very rare association between intraepithelial, extramammary Paget's disease and human papillomavirus- (HPV) negative, keratinized type of VIN III observed in two elderly women. In both cases, morphological and immunohistochemical investigation showed two heterogeneous but intimately admixed neoplastic populations of vulvar epithelium. Atypical keratinocytes stained markedly and diffusely positive for high molecular weight cytokeratins, and moderately for p53 protein and c-erbB-2 immunostainings. Paget cells were diffusely positive for CEA, EMA, and low molecular weight cytokeratins, moderately and focally for c-erbB-2 and (in one case) for S-100. Morphological and immunohistochemical phenotypic differences between Paget cells and atypical keratinocytes suggest a simultaneous and incidental association of two distinct neoplastic disorders more than a mixed carcinoma in situ of vulvar epithelium.     

Sentinel lymph node biopsy: benefits and limitations

Multiple studies have demonstrated that a sentinel node can be identified in most women with breast cancer, and that it reliably predicts the status of the remaining axillary nodes. Contraindications to the procedure are decreasing with experience but further long term follow up is needed.     

Recurrent cervical carcinoma after radical hysterectomy and pelvic lymph node dissection: a study of 32 cases

PURPOSE OF INVESTIGATION: To investigate the characteristics of patients with recurrent cervical carcinoma after radical hysterectomy and pelvic lymph node dissection (RHND), and to evaluate the effect of clinical and surgical pathologic factors on the outcome of these patients. METHODS: Data from the files of 32 patients with recurrent cervical carcinoma after RHND managed at the Soroka Medical Center from 1962 through 2005 were analyzed. RESULTS: These 32 patients represent a recurrence rate of 25.4%. The median recurrence-free interval was 19.3 (range, 1-106) months. The prevailing signs and symptoms were obstructive nephropathy, sacral pain and bowel obstruction. Sixteen (50%) patients had loco-regional recurrence alone, 12 (27.5%) loco-regional plus distant recurrence, and four (12.5%) distant recurrence alone. Treatment modalities included radiotherapy, chemotherapy and various surgical procedures. The 5-year survival rate was 35%, with 22 (68.7%) of the patients dead of disease at the end of follow-up. Univariate analysis demonstrated a significant worsening in survival with each of the following factors: loco-regional plus distant recurrence (p = 0.010), positive pelvic lymph nodes (p = 0.010), tumor size > or = 3 cm (p = 0.013), positive lymph vascular space involvement (p = 0.017) and RHND without bilateral salpingo-oophorectomy (p = 0.042). In a multivariate analysis, extent of recurrent disease (locoregional alone versus loco-regional plus distant recurrence) and pelvic lymph node status (negative vs positive) at RHND were the only significant predictors of survival. Uremia was the most common cause of death. CONCLUSIONS: Recurrent cervical carcinoma after RHND is a grave disease with unfavorable prognosis. In both univariate and multivariate analyses, extent of recurrent disease and pelvic lymph node status at RHND were significant predictors of survival.     

Paraaortic lymph node biopsy: A twenty-year study

OBJECTIVES: Paraaortic lymph node biopsy is a controversial but proved technique to determine the extent of spread of cancers from the uterine cervix or endometrium. This article explores the following questions. Does the presence of positive paraaortic lymph nodes result in modification of the patient's therapy? Does the evidence gained from a paraaortic lymph note biopsy improve patient survival?STUDY DESIGN: Five hundred sixty-eight patients had paraaortic lymph node sampling in conjunction with another operative procedure between 1976 and 1995. Five hundred seven (89.3%) of these patients had either endometrial or cervical cancer.RESULTS: Paraaortic lymph node biopsies led to a survival rate of 9.1% for cervical carcinoma and 46.6% for endometrial carcinoma and were associated with acceptable morbidity.CONCLUSIONS: We believe that paraaortic lymph node biopsies should be part of the routine evaluation of patients with gynecologic cancers. The knowledge gained by this procedure along with appropriately administered radiation therapy can save lives. (Am J Obstet Gynecol 1997;176:1157-65.)