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.

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.

Primary care in the postmenopausal woman.

For the obstetrician/gynecologist to function as a primary care physician he or she must be aware of all aspects of the patient's health care needs. Nutrition, weight control, exercise programs, and immunization are essential components of health maintenance. One must be alert to the development of chronic disease and disability, and utilize available screening techniques wisely and effectively. Education can increase compliance and sometimes modify harmful behavior. Informing the patient regarding common changes at menopause and beyond may smooth the transition. A sympathetic and supportive approach, along with judicious use of pharmacologic agents, should help each woman maintain the level of performance to which she is accustomed.

Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele.

During a 12-year study period from 1972 to 1984, 56 patients underwent abdominal sacral colpopexy with retroperitoneal interposition of a suspensory hammock between a prolapsed vaginal vault and the anterior surface of the sacrum. They were followed from 6 months to 12 1/2 years, and constitute the basis of this report. In most patients, a synthetic mesh was the material interposed. Hysterectomy had previously been performed on 53 patients, and in two patients there was congenital absence of the uterus. Indications for abdominal sacral colpopexy, surgical technique, complications, and results of operation are discussed. Seven additional patients underwent this operation after termination of the defined study period.

Management of stage IA carcinoma of the cervix.

One hundred fourteen patients with Stage IA carcinoma of the cervix were retrospectively reviewed in regard to depth of invasion, capillary-like space involvement, stromal reaction, status of conization margins, and the incidence of lymph node metastasis. Type of treatment, recurrences, and deaths were also evaluated. Patients with less than 3 mm invasion can be treated conservatively, including conization, if fertility is desired. No lymph node metastasis or recurrence appeared in this group of patients irrespective of type of treatment. Patients with 3 to 5 mm invasion do appear to be at higher risk for recurrence, but conservative therapy may be used in individualized situations. Size of conization and status of surgical margins appear to be important determining factors in regard to conservative therapy. Data in the literature, as well as our experience, although limited, suggest that the status of capillary-like space involvement does not influence lymph node metastasis or recurrence. Invasion of 5 mm or more in depth should be treated as a Stage IB occult lesion.

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.

Surgical management of rectovaginal fistulas in Crohn's disease.

An analysis of 15 patients with rectovaginal fistulas complicating Crohn's disease, who were managed at Duke Medical Center between 1966 and 1979, is presented. The experience reported suggests that, in carefully selected patients, and with proper timing of operative intervention, the role of primary repair of these fistulas may be more important and yield greater success than is generally maintained in the literature. Selection of the patients, perioperative management, and surgical technique are discussed.

Risk of exogenous estrogen therapy and endometrial cancer.

A retrospective study was carried out on 431 patients with endometrial cancer and 431 control subjects matched as to age, race, and parity. They were seen at Duke University Medical Center from 1940 to 1975. The study was performed in order to evaluate the risk of exogenous estrogen therapy and the development of adenocarcinoma of the endometrium. The overall risk was 2.38, with certain subgroups demonstrating different degrees of risk. Increased risk was associated with estrogen therapy of longer than 5 years' duration in white patients. The risk also was confined to Stage I, grade 1 lesions and more superficial myometrial invasion. Five-year survival for patients who used estrogen replacement and had Stage I, grade 1 lesions was 94.7%. The risks associated with exogenous estrogens are real but should be considered in a risk/benefit context when prescribing for the needs of an individual patient.

PIP: 431 endometrial cancer patients and 431 age-, race-, and parity-matched controls were studied retrospectively to assess the risk of endometrial adenocarcinoma (excluding Stage 0) associated with exogenous estrogen therapy; risk evaluations are presented. The study was concerned with patients at the Duke University Medical Center from 1940-1975. Overall, the risk of endometrial cancer associated with exogenous estrogen use was 2.38; subgroups demonstrated differing degrees of risk, e.g., use-duration, race, and invasiveness. Increased risk was associated with duration of greater than 5 years and with whites. Risk was also confined to Stage 1, Grade 1 myometrial superficial invasive changes. It was determined that the 5-year survival for patients who used estrogen replacement and had Stage 1, Grade 1 lesions was 94.7%; hence, the authors advocate careful attention to the risk-benefit notion in this therapy, given the high incidence of survival, the minimal risk of severe disease, and the beneficial effects of estrogen replacement.

Fascia lata urethrovesical suspension for recurrent stress urinary incontinence.

Although the physiologic mechanisms of normal micturition in the female subject are not fully understood, it is generally believed that urinary continence is maintained by a competent urethrovesical neck. Unfortunately, the patient who has had multiple operations for recurrent stress urinary incontinence often has a urethra that is shortened and fixed in scar tissue. In such patients, anterior colporrhaphy with operative release of the periurethral fibrosis and plication of the endopelvic fascia to create a functionally more normal urethrovesical junction will increase the chances for good results. A fascia lata support of the proximal 1 to 2 cm of the urethra ensures continued elevation of the urethra and with stress the sling provides a pulling-up effect. Fifty patients with a suburethral sling procedure are presented in detail. Forty-seven of these patients had a total of 121 prior operative procedures for stress urinary incontinence. Urologic studies are outlined. Forty-two patients (84%) were continent postoperatively, five were improved, and three had failures. Operative technique and complications are discussed.

Effects of long-term estrogen replacement therapy. II. Neoplasia.

Two groups of hypoestrogenic women are analyzed by retrospective comparison. Patients were observed by a single group of physicians for at least five years -- 301 patients treated with replacement estrogen and 309 untreated patients. Of each group, 207 women had uteri in situ. Incidence figures for neoplasia (gynecologic, breast, and all sites) were compared between the two groups and with the Third National Cancer Survey, yielding a risk ratio for the development of adenocarcinoma of the endometrium among estrogen-treated women of 3.8 and 9.3, respectively. There was no increase among any other malignancies. The addition of synthetic progestin to estrogen therapy provided significant protection against the likelihood of developing endometrial cancer and did not reduce previously reported metabolic benefits of estrogen treatment. Data pertaining to estrogen use and details of the patients with endometrial carcinoma are presented.

PIP: The effects of long-term estrogen replacement therapy upon neoplastic diseases were studied in 301 treated patients and 309 untreated patients. 207 women of each group had uteri in situ. Incidence figures for neoplasia were compared between the 2 groups and with the Third National Cancer Survey, yielding a risk ratio for the development of adenocarcinoma of the endometrium among estrogen-treated women of 3.8 (p .05) and 9.3, respectively. The addition of synthetic progestin to estrogen therapy provided significant (p .001) protection against the likelihood of developing endometrial cancer and did not reduce previously reported metabolic benefits of estrogen treatment. The data did not show an increased incidence of breast cancer among estrogen treated women, even with higher dosages or long-term therapy. It is recommended that estrogen therapy should be instituted whenever appropriate indications are present and no major contraindications exist; estrogen should be administered in the lowest dosage and duration that can adequately treat the indication for its use. Estrogens should probably be administered in cyclic fashion, especially if the uterus is in place, with sequentially added progestin.

Effects of long-term estrogen replacement therapy. I. Metabolic effects.

Two groups of hypoestrogenic women are analyzed by retrospective comparisons. Patients were observed by a single group of physicians for at least five years; 301 patients were treated with replacement estrogen and 309 patients were untreated. Incidence figures for various metabolic diseases present at entry and both during and after estrogen therapy were compared by the usual statistical analysis and by statistical adjustments for certain group differences (Mantel-Haenszel statistic). The long-term administration of estrogen to these relatively young women with hypoestrogenism was associated with significantly lower rates of development of cardiovascular disease, hypertension, osteoporosis, and fractures. Detrimental effects were a higher rate of abnormal uterine bleeding and an increase in the likelihood of developing adenocarcinoma of the endometrium. Effects of estrogen preparation, dosage, method of therapy, duration of therapy, and the addition of synthetic progestins are presented.

PIP: Metabolic effects of long-term (at least 5 years) estrogen replacement therapy were studied. 301 patients were treated with replacement estrogen and 309 patients were untreated. Incidence figures for various metabolic diseases present at entry, and both during and after estrogen therapy were compared by statistical adjustments for certain group differences (Mantel-Haenszel statistics) and by statistical analysis. Long-term administration of estrogen to these women with hypoestrogenism was associated with significantly lower rates of development of cardiovascular disease (p .001), hypertension (p .001), osteoporosis (p .001), and fractures (p .01). The detrimental effects included a higher rate of abnormal uterine bleeding (47% of 207 women with uteri in situ) and an increase in the likelihood of developing adenocarcinoma of the endometrium. Cyclic adminsitration of estrogen did not seem to protect from the risk of endometrial carcinoma, however the addition of progesterone to sequential estrogen treatment did. It is believed that long-term estrogen therapy is of benefit for the woman deprived of estrogen function, particularly if this loss occurs at a relatively young age.

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.

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.