Management of cervical intraepithelial neoplasia during pregnancy with LOOP excision.

OBJECTIVE: Management of severe cervical dysplasia/possible microinvasive carcinoma during pregnancy is frequently associated with significant morbidity. The purpose of this study is to determine the efficacy of LOOP excision performed during pregnancy, and also to record the nature and frequency of complications of the procedure. METHODS: Twenty women underwent LOOP excision during pregnancy. The gestational age range was 8-34 weeks. Data concerning indications, complications, and histopathologic results were recorded. RESULTS: Fourteen of 20 (70%) had dysplastic changes in the LOOP specimen. Eight of 14 (57%) had involved margins. Nine of 19 (47%) had residual dysplasia 3 months postpartum, including 3 patients whose initial LOOP specimens were negative for dysplasia. Significant morbidity included 3 preterm births, 2 patients who required blood transfusion following LOOP, and 1 unexplained intrauterine fetal demise documented 4 weeks post-LOOP. The gestational age range of those patients who had significant morbidity was 27-34 weeks. CONCLUSIONS: LOOP excision of the cervix during pregnancy does not consistently produce diagnostic specimens and is associated with a significant rate of residual disease. Morbidity appears similar to that of cone biopsy during pregnancy and occurs primarily when the procedure is performed in the third trimester. Until refinements in technique occur, LOOP excision during pregnancy should be reserved for limited indications.

Cervical carcinoma in women less than 35 years of age.

We retrospectively studied 80 patients, less than 35 years old, who were being treated for invasive cervical carcinoma at Charity Hospital of Louisiana in New Orleans. The period covered by the study was March 1980 to November 1989. The study group represented 9.3% (80/862) of the total patients seen with the disease. Disease stage was IB in 50 patients, IIA in 4, IIB in 14, IIIA in 5, IIIB in 6, and IVA in 1 patient. Histopathologic classes included 74 squamous cell carcinomas, 3 adenosquamous carcinomas, 2 adenocarcinomas, and 1 anaplastic carcinoma. Treatment used was either radical hysterectomy, irradiation alone, or irradiation followed by hysterectomy. Five-year actuarial survival rates were as follows: stage IB, 81.6%; stage IIA, 25.0%; stage IIB, 29.8%; stage IIIA, 20.0%; and stage IIIB, 33.4%. The only patient with stage IV cancer died of disease. Our findings do not reveal a relationship between age and survival in stage IB carcinoma of the cervix, and the numbers in the other stages are too small to comment on.

Magnetic resonance imaging of adult ovarian granulosa cell tumor. Case report.

We report the magnetic resonance imaging (MRI) findings in a unilocular multicystic adult granulosa cell tumor of the ovary. MRI, in conjunction with the clinical and laboratory findings, helped establish a preoperative diagnosis.

Ovarian choriocarcinoma: a difficult diagnosis of an unusual tumor and a review of the hook effect.

Ovarian choriocarcinoma is difficult to diagnose in the reproductive-age patient. A case of nongestational ovarian choriocarcinoma is discussed which presented like a molar pregnancy initially. Because of falsely low beta-hCG values (283 mIU/L) caused by the high-dose "hook effect" in the double antibody immunoassay system, however, a diagnosis of ectopic pregnancy was entertained. At laparotomy, a large necrotic ovarian choriocarcinoma was found along with large theca lutein cysts. The hook effect may mislead the clinician, and it is important to recognize this effect to avoid misdiagnosis.

Paget's disease of the vulva and urogenital malignancies: a case report and review of the literature.

The vulva is one of the extramammary sites which has a potential for developing Paget's Disease with which an underlying sweat gland carcinoma or breast carcinoma is frequently associated. Urogenital malignancy may be a third contender. Such a case managed by the authors herein reported and a review of the literature about such lesions support this assumption.

Verrucous carcinoma of the cervix: a report of two cases and literature review.

Verrucous carcinoma of the cervix, like verrucous carcinoma of the vulva, is commonly misinterpreted as condyloma accuminata, resulting in a protracted delay of appropriate treatment. Since the correct diagnosis depends upon histological criterion which frequently belies the malignant nature of this lesion, conveyance to the pathologist of the history, physical findings, and clinical behavior of the lesion may facilitate early recognition. Aggressive surgical procedures including exenteration should be considered as primary treatment for large lesions and recurrent lesions when local excision fails. Radiotherapy is not usually an effective treatment for verrucous carcinoma and may induce malignant transformation. To date, 27 cases of verrucous carcinoma of the cervix have been reported. Two additional cases managed in recent years by the authors and a review of the world's literature about this uncommon lesion form the basis of this report.

Granular cell tumor of the clitoris in pregnancy.

Granular cell tumors of the female genital organs represent 7-15% of all granular cell tumors reported in the literature. The majority of these genital lesions are located on the vulva. Granular cell tumor involving the clitoris is extremely rare and should be considered in the differential diagnosis of clitoral masses.

Ultrasound and the pelvic mass.

We compared the findings from pelvic examination, preoperative ultrasound and surgery on 50 patients who underwent exploratory laparotomy for a pelvic mass at Tulane University Medical Center. Of the 50 cases, 34 (68%) were correctly diagnosed as a pelvic mass by both pelvic examination and ultrasonography. Ultrasound had nine false negatives (21%) and only one false positive (2%). Pelvic examination had 7 false positives (16%). There was no statistical difference by chi-square analysis in the accuracy between ultrasonography and pelvic examination in the detection or diagnosis of the masses. Ultrasound indicated pathology not associated with the suspected mass in ten patients; surgery confirmed pathology in five of them. More errors occurred on both pelvic examination and ultrasonography in obese patients than in nonobese ones: seven of the ten ultrasound errors occurred in obese patients, and five of the seven pelvic exam errors also occurred in obese patients. In the nine cases of false-negative ultrasound findings surgery was postponed, but all of them eventually underwent surgery because of a deteriorating clinical course. In our study pelvic ultrasonography was not beneficial in the management of patients with a known or suspected pelvic mass, but it was very accurate for confirmation of a mass.

Irradiation of liver metastases due to gestational choriocarcinoma.

One of the major unresolved problems in high-risk choriocarcinoma is the prevention of hemorrhage from tumor necrosis during chemotherapy. The authors report a successfully treated patient who developed intrahepatic bleeding while receiving systemic chemotherapy and concomitant whole liver irradiation. Patients with trophoblastic liver metastases are at risk for bleeding from tumor necrosis during chemotherapy but, because there are few reported cases, the degree of risk cannot be predicted. Radiation therapy for the prevention of this complication may not be as successful for liver metastases as it is for brain metastases; reports are too scarce to evaluate its efficacy. As demonstrated in the present patient, radiation therapy does not completely eliminate the risk of hemorrhage from chemotherapy. The hypothesis that patients with liver metastases from gestational choriocarcinoma are more susceptible to treatment failure and life-threatening complications than other members of the high-risk category needs support. Other investigators are encouraged to report their results with trophoblastic liver metastases to clarify the type and degree of risk, to determine the role of adjuvant radiation therapy, and to establish optimum treatment protocols.

Herpes gestationis associated with choriocarcinoma.

Herpes gestationis (HG) is a rare, vesicobullous dermatosis of pregnancy or the puerperium. It has been associated with hydatid mole and the use of oral contraceptives. Reports of HG and choriocarcinoma are extremely rare: only two cases have been reported. Metastatic choriocarcinoma, followed by a pruritic, bullous eruption, developed in a 36-year-old woman. A biopsy specimen of the lesions showed subepidermal bullae, with an eosinophilic infiltrate. Direct immunofluorescent microscopic findings showed IgG and C3 deposition at the basement membrane zone, establishing the diagnosis of HG. Methotrexate therapy produced a cure of the carcinoma and a simultaneous resolution of the skin lesions. To our knowledge, this is the first report of the association of HG and choriocarcinoma with immunofluorescent microscopic findings.