Rare periorbital, pseudocystic metastasis of squamous cell carcinoma of the bladder: Case report and review of the literature.

We present the case of a man in his fifties with a history of bladder carcinoma who presented with a large periorbital cystic lesion that was found to be a metastasis. Bladder carcinomas are a very rare cause of peri-/orbital metastasis. The primary tumor in this case predominately showed squamous cell differentiation and small areas of adenoid differentiation. To our knowledge only one previous case of orbital metastasis from squamous cell carcinoma of the bladder has been reported. Cyst formation in bladder cancer metastasis has not been reported and is very rare for orbital metastases in general. The pathogenesis of metastatic cyst development is not fully understood and may vary from case to case. A biopsy of an atypical cyst is indicated.

The next twenty-five years.

The next 25 years have been reviewed from the general standpoint of people and economy and from the specific focus of the health care needs of women. Special problems in patient care which will require our immediate attention have been identified. The strengths and weaknesses of the College have been presented. A proposal for reinforcement of organization within the discipline to help us pull together as a team is the creation of 1) A Coordinating Council For Obstetrics and Gynecology; and 2) A Board of Trustees for the American College. These steps I believe are essential to the health growth of our College and the advancement of quality education and improved patient care.

Rupture of the pregnant uterus: a 53-year review.

A 53-year (1931-1983) review of 48 patients who experienced uterine rupture and were cared for at Duke University Medical Center was conducted. The observed incidence was one uterine rupture per 1424 deliveries. From January 1, 1963, through December 31, 1983, 24 cases of ruptured uterus were identified; a detailed review of these patients is presented.

Choice of analgesia or anesthesia for pain relief in suction curettage.

One hundred and fifteen patients admitted to Duke University Medical Center from January 1, 1973, to December 31, 1974 inclusive, with the diagnosis of uncomplicated spontaneous incomplete or inevitable abortion were included in a randomized prospective study. All patients underwent suction curettage under either analgesia or general inhalation anesthesia. Patient response was adjudged regarding comfort and cooperativeness in the group receiving analgesia and postprocedure rehabilitation and discharge times in both groups. Fifteen of 59 patients receiving analgesia only were recorded unanimously as failures. Post-operative ambulation was no more rapid in patients receiving analgesia. Procedure-to-discharge intervals were unrelated to medication modality. There appears to be no advantage to analgesia as far as rehabilitation time, procedure-to-discharge time, and medical complications are concerned.

Fertility after cryosurgery of the cervix.

Fertility in patients following cryosurgery of the cervix was evaluated in 412 women. Cryosurgery does not appear to have any effect on subsequent fertility when compared with the general population.

Germ cell malignancies of the ovary.

Historically, ovarian germ cell malignancies carry a very poor prognosis. The use of surgery alone or in combination with radiation therapy does not appreciably increase survival. The combination of surgery, chemotherapy, and, in some instances, radiation therapy has accounted for an 89% two-year survival in 26 patients with germ cell malignancies of the ovary exclusive of "pure" dysgerminoma. Short-term chemotherapy appears as effective as the long-term therapy advocated by other investigators.

Arteriography and infusional chemotherapy in localized trophoblastic disease.

Despite recent advances in the systemic chemotherapy of patients with malignant trophoblastic disease, there remains a small group of patients who fail to achieve remission with this type of treatment. The present study presents 19 patients with malignant trophoblastic disease who underwent a total of 25 arteriographic studies for localization of persistent malignant lesions and 8 patients who underwent arterial infusional chemotherapy after they had failed to achieve remission by standard administration of systemic methotrexate or actinomycin D. Patients underwent pelvic, pulmonary, carotid, and multiple abdominal selective arteriograms with a high correlation of positive findings and the later documented presence of persistent malignant disease. Findings include prominent uterine arteries, arteriovenous shunts, hypervascularity, irregular vessels, and tumor staining within the tumor. Arterially infused chemotherapy with methotrexate or actinomycin D was used in 8 patients whose disease was resistant to systemic chemotherapy. Technics of arterial infusion are discussed.

Hydatidiform mole: diagnosis, management, and long-term followup of 347 patients.

This report concerns 347 patients with primary hydatidiform moles studied during the first 6 years (1966-1972) of operation of the Southeastern Regional Trophoblastic Disease Center. Aside from a decreased incidence, molar pregnancy in the United States follows a pattern similar to that elsewhere in the world. Abnormal bleeding is the key to early diagnosis, and the frequent use of sensitive HCG assays is the key to proper followup. Twenty percent of patients with hydatidiform moles can be expected to develop subsequent malignant sequelae. Bilateral ovarian enlargement and/or a large-for-dates- uterus should alert the physician to a greater potential for this outcome. Spontaneous elimination of HCG from the circulation following moler pregnancy, as indicated by sensitive assay, would predict a benign postmolar course; no patient in the current series who once achieved undetectable levels of HCG developed malignant trophoblastic disease.

Urologic and genital anomalies in patients with congenital absence of the vagina.

Forty-three patients with primary amenorrhea secondary to congenital absence of the vagina have been seen at this institution over the past 25 years. Associated urologic anomalies were present in 47% of patients in whom evaluation of the urinary tract was performed. Two patients recently presented with the rare combination of vaginal agenesis and solitary pelvic kidney, and one other such patient was found in a retrospective study of these records. A review of the literature concerning the associations of these conditions is presented with reference to frequency, embryology, pathophysiology, diagnostic methods, and various surgical procedures for correction of vaginal agenesis. The results of surgical correction using simple techniques in this institution have been comparable to those of other authors. The need for thorough preoperative evaluation of patients with genital malformations to include complete urologic studies is stressed.

Peripartum hysterectomy: a review of cesarean and postpartum hysterectomy.

A retrospective review of 117 women who underwent peripartum hysterectomy at Duke University Medical Center during the past 21 years was conducted. Seventy-three cesarean hysterectomies were performed electively; 44 cesarean or postpartum hysterectomies were performed as emergencies. Statistically significant differences were noted between these groups in surgical technique, operative time, estimated blood loss, intraoperative hypotension, and intraoperative and total blood replacement. Additional significant differences were noted in postoperative febrile morbidity, use of therapeutic antibiotics, incidence of thromboembolic phenomena, and length of postoperative hospital stay. Separate analysis of elective cesarean hysterectomy patients revealed statistically significant decreases in operative time, estimated blood loss, intraoperative and total blood replacement, and postoperative hospital stay in the group having an experienced surgeon when compared with the group with less experienced surgeons.

A computerized obstetric medical record.

Duke University has utilized computerized obstetric medical records since 1971. System evolution is described. Deficiencies in the current system appear to evolve from the computer/human interface rather than from basic system design. Critical elements in system success are physician acceptance of the appearance of data collection sheets and printed notes and continual rapid response in programing modification to allow for physician individuality and changes in medical practice. The limiting factor in the potential usefulness of such a system is the rate of incomplete data collection. It is suggested that if the physician were to enter data directly into the computer through a terminal, data collection would be more accurate and complete.

Conservative treatment of endometriosis externa: the effects of methyltestosterone therapy.

Twenty-four women with documented endometriosis externa were treated with methyltestosterone. Twenty-one of these patients desired fertility and three conceived (one after methyltestosterone therapy alone, two after conservative operation followed by methyltestosterone treatment). Ten patients later required surgical therapy for recurrence of pain, although all but one patient had initial relief of pain (3 to 6 months after therapy). These results of therapy are contrasted to those of similar studies in the literature in which methyltestosterone and other agents were used.

Conservative treatment of endometriosis: the effects of limited surgery and hormonal pseudopregnancy.

This study compares the effects of limited surgery or hormonal pseudopregnancy, or a combination of these two, upon fertility and the need for subsequent surgery with respect to the extent of the disease at the time of initial diagnosis in patients with endometriosis externa. Of the 61 patients who desired to enhance or preserve reproductive capacity, 20 patients became pregnant, for a pregnancy rate of 33%. The pregnancy rate in all categories, that is, those patients treated with pseudopregnancy, conservative surgery, and combined pseudopregnancy and surgery, was found to be in direct relationship to the initial extent of disease. In such patients, conservative surgery alone seemed to give the best results in the achievement of pregnancy. There seemed to be little difference between pseudopregnancy alone and conservative surgery in regard to the need for subsequent surgery after initial therapy, although there seemed to be a significantly greater chance for the need for subsequent surgery in patients receiving a combination of the two forms of therapy. The need for subsequent surgery after initial therapy in 80 patients increased in direct relationship to the initial extent of disease present, despite the form of therapy used. Fifty-nine other patients with endometriosis, who did not desire to preserve fertility and presented for relief of other symptoms, underwent initial "radical" therapy. Forty-six patients underwent complete operation, including removal of uterus, tubes and ovaries, and none required subsequent reoperation. Of the 13 remaining patients, who underwent incomplete surgical removal, leaving one or both ovaries in situ, 11 required subsequent reoperation for recurrent pelvic endometriosis.