Heterotopic bone in the ovary associated with a mucinous cystadenoma.

Bone formation in the ovary, with the exception of developing in the setting of a mature cystic teratoma, is exceedingly uncommon. We report a case of bone formation within a mucinous cystadenoma of the ovary. A 19-year-old active duty female presented with an asymptomatic pelvic mass; sonographic imaging revealed a 5.7-cm complex right adnexal mass. A laparoscopic cystectomy was performed. Pathologic evaluation of the cyst revealed a mucinous cystadenoma. Contained within several of the thick fibrous septae were areas of well-formed bone. Although a benign finding, bone formation and associated fibrosis may lead to sonographic findings of concern during the evaluation of patients with a pelvic mass.

Spindle cell lipoma of the female genital tract. A report of two cases.

BACKGROUND: Lipomas presenting in the female genital tract are most commonly seen in the vulva or myometrium as a component of a leiomyoma. These lesions have the gross appearance of a typical lipoma. CASES: Two cases of spindle cell lipoma occurred, one incidentally encountered in the cervix and the other presenting as a vulvar mass. Both lesions demonstrated histologic features characteristic of spindle cell lipomas normally found elsewhere, and the diagnosis was supported by immunohistochemical staining patterns. CONCLUSION: This is the first report of spindle cell lipomas diagnosed in the female genital tract.

Placenta increta/percreta associated with uterine perforation during therapy for fetal death. A case report.

BACKGROUND: Placenta accreta involves abnormal adherence of the placenta to the myometrium. Placenta increta and percreta are defined by the degree of trophoblastic penetration of the myometrium. These conditions are rarely observed in the first trimester; placenta increta and percreta are exceptionally infrequent. CASE: A woman had a uterine perforation after suction curettage for fetal death at 11 weeks' gestation, requiring hysterectomy for control of a profuse hemorrhage. Histopathologic examination of the uterus revealed placenta increta involving the lower uterine segment and placenta percreta at the site of uterine perforation. CONCLUSION: This is the first report of placenta percreta associated with uterine perforation during therapy for first-trimester fetal death.

Melanosis of the vagina. A case report.

BACKGROUND: Melanosis is a term given to lesions in which melanin pigment is confined to the basal layer of squamous epithelium and on visual inspection may have an appearance similar to that of malignant melanoma. Although relatively common in the oral and gastrointestinal tract, melanosis is an uncommon finding in the female genital tract and especially rare in the vagina; most reported cases have been vulvar. CASE: A 43-year-old, nulliparous woman was noted to have a pigmented lesion at the vaginal cuff during a routine annual examination one year after a hysterectomy. On physical examination, the lesion appeared as a coalescence of several small, pigmented areas at the cuff. On palpation the lesion was flat, having the contour of normal vaginal mucosa, and was not indurated or tender. A biopsy revealed vaginal melanosis. The patient was followed conservatively, with annual examinations, which documented no change in color, size or contour of the lesion. At this writing the patient is six years from presentation and doing well. CONCLUSION: Vaginal melanosis may be difficult to distinguish clinically from malignant melanoma but carries a much different prognosis. A biopsy of any pigmented lesion is always indicated prior to determining the need for therapy versus observation.

Recurrence of dysplasia after loop electrosurgical excision procedures with long-term follow-up.

OBJECTIVE: The aim of this study was to determine the rates of recurrent dysplasia with longer follow-up durations and to determine whether margin status and other variables were associated with recurrence. STUDY DESIGN: A retrospective chart review was performed for all women who underwent a loop electrosurgical excision procedure at Wilford Hall Medical Center, Lackland Air Force Base, Texas, between January 1993 and December 1994. Extracted information included age, parity, indication for the loop electrosurgical excision procedure, histologic classification of the loop electrosurgical excision procedure specimen, margin status, and whether a "deep" (endocervical) pass had been performed. Follow-up data included findings of repeated cytologic examination, colposcopy, and biopsy if performed. RESULTS: The mean duration of follow-up for all women was 24 months. Margins were positive in 28%, with 73% of these being endocervical. The overall recurrent dysplasia rate was 31%, with a mean time to recurrence of 11.9 months. Participants with any positive margins had a higher recurrence rate than did those with negative margins (47% vs 26%; P = .009). High-grade lesions at the margin were more commonly associated with recurrence than were low-grade lesions relative to those with clear margins (high-grade lesion vs negative margins, 55% vs 26%; P = .003; low-grade lesion vs negative margins, 36% vs 26%; P = .34). Recurrence was not associated either with the performance of an endocervical pass or with the histologic diagnosis of the loop electrosurgical excision procedure specimen. CONCLUSION: With comprehensive long-term follow-up, positive margins on loop electrosurgical excision procedure specimens were shown to be a risk factor for recurrence of cervical dysplasia, particularly when high-grade lesions were seen at the margin. Recurrence was also considerable among women with negative margins. Women should be counseled regarding this risk, and the importance of follow-up should be emphasized.

Primary peritoneal psammocarcinoma: A case presenting with an upper abdominal mass and elevated CA-125.

Primary peritoneal serous adenocarcinoma with predominating psammoma bodies, psammocarcinoma, is a very rare tumor with only seven cases documented in the English literature. Pathological classification of this entity was established in 1990 and clinical behavior of this tumor is uncertain. Based on limited data these tumors appear to behave similarly to low malignant potential tumors of the ovary. This case describes a 59-year-old woman who underwent exploratory laparotomy for a large upper abdominal cystic mass. Findings included a large tumor mass involving the gastrocolic omentum and dense small bowel adhesions. The patient had normal ovaries and was debulked to no macroscopic disease. Final pathologic diagnosis confirmed a stage IIIC primary peritoneal psammocarcinoma. The patient has received no adjunctive therapy and is without evidence of disease 2 years after surgery. Primary peritoneal psammocarcinoma is a neoplasm which can mimic serous adenocarcinoma of the ovary. In contrast, primary peritoneal psammocarcinoma appears to behave in an indolent fashion. Primary surgical debulking should be attempted, while the utility of postoperative chemotherapy remains unknown.

Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity.

OBJECTIVE: To review the management of puerperal vulvovaginal hematomas and report on the use of closed system drainage in cases in which operative intervention was used. STUDY DESIGN: A retrospective review of medical records for a five-year period was conducted. The charts of all patients in whom puerperal vulvovaginal hematomas occurred were reviewed and data extracted regarding possible etiologic factors, details of delivery, characterization of the hematoma, surgical intervention and type of drain used. Also recorded was length of stay and postoperative complications. RESULTS: Eleven patients with hematomas were identified, for an incidence of 1/526. All patients received antibiotics; transfusion was required in eight patients. Drains were used in nine patients: Penrose in four and closed system drainage in five. All drains were brought through a separate site distant from the repair. There was one postoperative abscess, which resolved with wound care, resulting in no long-term morbidity. CONCLUSION: Puerperal vulvovaginal hematomas may be a life-threatening event. Review of the literature and our experience suggests that aggressive operative management and the use of drains are beneficial in the management of these patients. Closed system drainage may be an effective adjunct in the management of vulvovaginal hematomas.

Disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis. A clinicopathologic analysis of 109 cases with emphasis on distinguishing pathologic features, site of origin, prognosis, and relationship to "pseudomyxoma peritonei".

Pseudomyxoma peritonei (PMP) is a poorly understood condition characterized by mucinous ascites and mucinous implants diffusely involving the peritoneal surfaces. There is considerable debate regarding the definition, pathology, site of origin, and prognosis of PMP. We analyzed the clinicopathologic features of 109 cases of multifocal peritoneal mucinous tumors to develop a pathologic definition of cases characterized by the clinical condition PMP. Cases were separated into two diagnostic categories: disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA). Cases classified as DPAM were characterized by peritoneal lesions composed of abundant extracellular mucin containing scant simple to focally proliferative mucinous epithelium with little cytologic atypia or mitotic activity, with or without an associated appendiceal mucinous adenoma. Cases classified as PMCA were characterized by peritoneal lesions composed of more abundant mucinous epithelium with the architectural and cytologic features of carcinoma, with or without an associated primary mucinous adenocarcinoma. Sixty-five of the 109 cases (59.6%) were classified as DPAM consistent with origin from an appendiceal mucinous adenoma. Thirty-seven of the 65 cases (56.9%) had a documented appendiceal mucinous adenoma. Thirty cases (27.5%) were classified as PMCA consistent with origin from an appendiceal or intestinal mucinous adenocarcinoma. Fourteen cases (12.8%) were classified as PMCA with features intermediate between DPAM and PMCA or with discordant features based on the finding of at least focal areas of carcinoma in the peritoneal lesions, whether or not the primary site demonstrated carcinoma. The cases with intermediate features were derived from well-differentiated appendiceal or intestinal mucinous adenocarcinomas and had peritoneal lesions displaying features of DPAM as well as focal areas of mucinous carcinoma. The cases with discordant features were derived from atypical appendiceal adenomas with little or no histologic evidence of a transition from adenoma to carcinoma and had peritoneal lesions uniformly composed of mucinous carcinoma. There was a statistically significant difference in survival between cases classified as DPAM, those classified as PMCA with intermediate or discordant features, and those classified as PMCA (p < 0.0001). The age-adjusted 5-year survival rates were 84% for patients with DPAM, 37.6% for patients with PMCA with intermediate or discordant features, and 6.7% for patients with PMCA. The term DPAM should be used to diagnose the histologically benign peritoneal lesions associated with ruptured appendiceal mucinous adenomas and those that are pathologically identical but lack a demonstrable appendiceal adenoma. Cases with the pathologic features of adenocarcinoma should be designated PMCA because they have recognizably different pathologic features and a significantly worse prognosis.

Endometrial intraepithelial carcinoma: a distinctive lesion specifically associated with tumors displaying serous differentiation.

Endometrial intraepithelial carcinoma (EIC) is a recently described lesion characterized by replacement of endometrial surface epithelium or glands by malignant cells resembling high-grade invasive endometrial carcinoma. EIC has been identified in a high proportion of uteri containing serous carcinoma, but its association with other endometrial tumors is unknown. To determine the strength and specificity of the association of EIC with tumors displaying serous differentiation, the appearance of the endometrium in 38 uteri with serous carcinoma, 113 with endometrioid carcinoma, and 34 with malignant mixed mesodermal tumor (MMMT) were compared. EIC was present in 34 (98%) uteri with serous carcinoma compared with 7 (6%) uteri removed for endometrioid carcinoma (P = .0001). Hyperplasia without atypia was found in only 2 (5%) of 38 serous carcinomas compared with 38 (34%) of 113 endometrioid carcinomas. Similarly, atypical hyperplasia was not found in any uterus with serous carcinoma, but was present in 14 (12%) uteri with endometrioid carcinoma (P = .02). The endometrium was inactive or atrophic in 29 (76%) patients with serous carcinoma compared with 33 (29%) with endometrioid carcinoma (P = .0001). EIC was found in five (56%) of nine MMMTs with a serous epithelial component (serous-MMMT) compared with one (4%) of 25 MMMTs woth an endometrioid epithelial component (endometrioid-MMMT). As with endometrioid and serous carcinomas, hyperplasia with and without atypia was more common with endometrioid-MMMTs as compared with serous-MMMTs. Hyperplasia was found in 25 (100%) and atypical hyperplasia in 8 (32%) of 25 endometrioid-MMMTs, but in none of the nine serous-MMMTs. This study shows that EIC is frequently and specifically associated with uterine tumors displaying serous differentiation. The findings suggest that EIC represents a form of intraepithelial tumor growth characteristic of serous carcinoma and serous MMMT and that EIC is the likely precursor of these neoplasms. In addition, the findings provide further evidence supporting the view that MMMTs represent variants of carcinoma not sarcoma.

Pseudomyxoma peritonei in women: a clinicopathologic analysis of 30 cases with emphasis on site of origin, prognosis, and relationship to ovarian mucinous tumors of low malignant potential.

Pseudomyxoma peritonei (PMP) is a poorly understood condition characterized by the accumulation of abundant mucinous material within the peritoneal cavity and associated with a mucinous tumor of the gastrointestinal tract or ovaries. Recently there has been considerable debate over the primary site of origin of the tumor associated with PMP in women. Some investigators have proposed a primary site in the ovaries, whereas others favor the gastrointestinal tract or the peritoneum. Another confusing issue has been the nature of the ovarian mucinous tumors associated with PMP. Although these neoplasms may be frankly malignant, more often they show minimal cytologic atypia and epithelial proliferation and have been classified as borderline or low malignant potential tumors. In order to address the issues of site of origin and nature of the associated ovarian mucinous tumors, we studied 68 cases of PMP in women, 30 of whom had mucinous tumors involving the ovaries. All 30 of these cases had an associated mucinous appendiceal or intestinal tumor. The PMP cases with ovarian tumors were compared with 30 ovarian mucinous tumors of low malignant potential (LMP). Based on the analysis of the primary ovarian mucinous LMP tumors, a set of criteria was formulated and used to determine the probable site of origin of PMP in the 30 women with mucinous tumors involving the ovaries. The following gross and microscopic features of the ovarian tumor were considered to be inconsistent with a primary ovarian origin: (1) surface involvement with or without superficial stromal involvement only; (2) adenocarcinoma with signet ring cell differentiation, with a previously diagnosed or concurrent appendiceal tumor of similar morphology; (3) bilateral adenocarcinoma consistent with colonic or appendiceal morphology; and (4) unilateral adenocarcinoma consistent with colonic or appendiceal morphology with a history of a colonic or appendiceal adenocarcinoma. When any one of these features was present the ovarian tumor was diagnosed as secondary. The following additional features also were considered to be more typical of secondary ovarian involvement: (1) normal or only slightly enlarged ovaries; (2) bilateral ovarian involvement; (3) simple or only focally proliferative mucinous epithelium with abundant extracellular mucin in cases with predominantly surface involvement of the ovaries, with or without a history of/or concurrent appendiceal adenoma; (4) multifocal or extensive pseudomyxoma ovarii in cases with stromal involvement, with or without a history of/or concurrent appendiceal adenoma; (5) ruptured appendiceal adenoma and unruptured ovarian tumor of similar histology; and (6) presence of an associated mucinous intestinal tumor.(ABSTRACT TRUNCATED AT 400 WORDS)

Karyotypic abnormalities and hydramnios. Role of amniocentesis.

Hydramnios complicates up to 1.6% of pregnancies, with major fetal malformations found in an average of 20% of patients with hydramnios. Chromosomal abnormalities, although associated with some conditions in which hydramnios is present, have not been reported to complicate a significant percentage of hydramnios cases. Data from 45 patients admitted during the period January 1, 1985-May 31, 1990, were analyzed. All patients had hydramnios sufficiently severe to merit hospitalization for diagnosis and/or treatment. Amniocentesis was performed at the discretion of the attending physician and not under a specific protocol. The incidence of major fetal structural malformations was 36%. Of patients in whom amniocentesis was performed, 22% were found to have karyotypic abnormalities, none of which was specifically suspected prior to the amniocenteses. Neither the estimated gestational age nor the assessment of the amount of amniotic fluid differed between those with karyotypic abnormalities and those with normal chromosome complements. This information suggests that both advanced ultrasound studies and amniocentesis are beneficial in the evaluation of hydramnios.

Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.

Puerperal hematomas, although rare, can be potentially morbid or life-threatening events. Early surgical management, including clot evacuation, layered closure, drainage, antibiotics, and fluid replacement (including blood), usually result in satisfactory outcome. Prevention is clearly preferable and often achievable with careful initial repair of episiotomies and lacerations.

Relapsing Clostridium difficile toxin-associated colitis in ovarian cancer patients treated with chemotherapy.

Symptomatic relapse of Clostridium difficile toxin-associated colitis occurred in three patients with ovarian cancer. In two patients, C difficile toxin-positive diarrhea initially appeared in association with antibiotic therapy. The third patient developed diarrhea after chemotherapy, without recent antecedent antibiotic administration. Patients were initially treated with oral metronidazole and became asymptomatic and toxin-negative. A symptomatic toxin-positive recurrence then developed after the subsequent course of systemic chemotherapy. Recurrent C difficile toxin-associated colitis or pseudomembranous colitis after chemotherapy has not been reported previously in the gynecologic oncology literature. Clostridium difficile-induced diarrhea must be considered in chemotherapy patients with diarrhea because management concepts vary from those for noninfectious diarrhea.