Ghadir Salame

Medical management of recurrent endometrioma with long-term norethindrone acetate.

Purpose Evaluate the efficacy of norethindrone acetate in the resolution of symptoms and regression of recurrent endometrioma. Patients and methods Retrospective chart review at SUNY Downstate Medical Center of patients with a history of surgical excision of endometrioma (with histological confirmation) and recurrent endometrioma (demonstrated by strict sonographic criterion of endometrioma) who were willing to undergo follow-up. Patients were prescribed norethindrone acetate to be taken daily with follow-up sonograms until cysts regressed. Statistical analysis included Student’s t-test and a simple linear regression model to assess cyst regression over time during treatment. Results Degree of pain was significantly lower on treatment when compared to baseline (P < 0.00001). Cyst size was significantly smaller in as little as 3 months (P < 0.0001). Average rate of regression with continuous treatment was 0.025 ± 0.015 cm/day. Total mean ± standard deviation regression time is 10.28 ± 8.25 months. Conclusion Norethindrone acetate was effective in eradicating symptoms and producing complete regression of recurrent endometriomas. It should be considered for patients who are likely to adhere to a prolonged treatment regimen and comply with recommendations for surveillance with serial sonograms.

Color Doppler sonographic features of a Krukenberg tumor in pregnancy

Brenner tumors, benign transitional cell tumors of the ovary, constitute approximately 3.1% of ovarian epithelial neoplasms. The mean patient age is 50 years. Most tumors are 2 cm or smaller, but occasionally they are large and may exceed 10 cm. Microscopically, the characteristic feature consists of sharply demarcated epithelial cell nests embedded in a dense fibrous stroma. Hyalinized areas are common, and dystrophic calcification is present in 50% of cases, often in the hyalinized areas. 1 Sonographic findings of benign Brenner tumors have been described and consist of solid hypoechoic masses, with calcifications noted at times. 2,3 In a recent study pertaining to the sonographic and computed tomographic features of this tumor including 22 women with 25 ovarian Brenner tumors, 16 of 25 (64%) were found incidentally. 3 We present an unusual case of a Brenner tumor complicating pregnancy and a description of the color Doppler sonographic features of this tumor in pregnancy.

Hydronephrosis as a prognostic indicator of survival in advanced cervix cancer.

Objective: To determine whether hydronephrosis is an independent prognostic indicator of survival among patients with advanced cervical carcinoma. Moreover, we wanted to demonstrate the relationship between unilateral and bilateral hydronephrosis and overall survival. Methods: Retrospective analysis of 197 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical carcinoma or higher treated between 1990 and 2007 was conducted. Inclusion criteria were clinical staging according to FIGO criteria, standardized radiation treatment and cisplatin-based chemosensitization regimens. Associations between hydronephrosis and covariates-age, race, histopathologic diagnosis, pelvic sidewall involvement, stage, nodal involvement, and Gynecologic Oncology Group/Eastern Cooperative Oncology Group performance status (PS)-were determined. Statistical analysis including Kaplan-Meier, log-rank test, proportional hazards regression, Fisher exact test, and Mann-Whitney test were used where appropriate, with P < 0.05 considered significant. Results: Of 143 included patients, 73 patients had no hydronephrosis (HN), 39 patients had unilateral HN, and 31 patients had bilateral HN. Twenty-nine patients (40%) with no HN died compared to 24 patients (61.5%) with unilateral HN and 21 patients (67.7%) with bilateral HN. Median time to death was significantly shorter for patients with unilateral HN (27 months; 95% confidence interval [CI], 10-48) and bilateral HN (12 months; 95% CI, 6-23) versus patients without HN (68 months; 95% CI, 39-∞; P < 0.001). Unadjusted hazard ratio (HR) for HN (both unilateral and bilateral) was 2.4 (95% CI, 1.5-3.8); P < 0.001. Of potential covariates evaluated, PS and sidewall involvement were significantly associated with HN (P = 0.021 and P = 0.014, respectively). Proportional hazards regression revealed that controlling for use of radiation, chemotherapy, and for PS, HN was still significantly associated with poor prognosis (HR unilateral HN = 2.0, 95% CI, 1.2-3.5; HR bilateral HN = 3.2, 95% CI, 1.7-6.0); P ≤ 0.001. Conclusion: Hydronephrosis is an independent poor prognostic indicator of survival in patients with advanced cervical cancer. Bilateral hydronephrosis compared to unilateral involvement confers a worse overall prognosis. Additional studies are needed to determine if FIGO staging should be amended.

Sonographic features associated with post-uterine artery embolization pyomyoma.

ilateral uterine artery embolization for symptomatic leiomyomata is an alternative to hysterectomy, providing good short-term relief of bulk-related symptoms and a reduction in menstrual flow.1 With increasing use of this therapeutic procedure, however, procedure-related complications have been reported. These include phenomena resulting from aberrant embolization (buttock and labial necrosis and vesicouterine fistula),2–5 in addition to prolapsed cervical myoma, uterine necrosis, ischemic uterine rupture, infectious sequelae including sepsis, volvulus, inadvertent embolization of a malignant leiomyosarcoma, and ovarian dysfunction.6–11 We present unusual sonographic features of post–uterine artery embolization pyomyoma.

Gestational diabetes leading to diagnosis and management of multiple endocrine neoplasia type 2a.

BACKGROUND: Multiple endocrine neoplasia (MEN) type 2a is an autosomal dominant syndrome caused by specific proto-oncogene mutations characterized by medullary carcinoma of the thyroid, pheochromocytoma, and, occasionally, multiglandular parathyroid hyperplasia, which rarely complicates pregnancy. Secondary diabetes rarely has been reported in association with principal endocrinopathies complicating pregnancy. CASE: A 34-year-old primiparous woman with recently diagnosed gestational diabetes had repeated episodes of dizziness at 30 weeks of gestation, initially attributed to glyburide. Continued episodes of dizziness and later-appearing bouts of severe headache, palpitations, diaphoresis, severe hypertension, and marked tachycardia led to diagnosis and management of MEN type 2a complicating pregnancy. CONCLUSION: Patients with MEN type 2a complicating pregnancy may present with gestational diabetes.

Sonographic and magnetic resonance imaging findings of pelvic abscess following uterine perforation sustained during office endometrial sampling.

Pipelle endometrial sampling, an outpatient, office‐based procedure, provides comparative successful endometrial sampling in comparison with other techniques including conventional dilatation and curettage. We present an unusual occurrence in which office Pipelle endometrial sampling in a perimenopausal patient was complicated 10 days later by lower abdominal pain and intermittent fever. Sonography depicted findings consistent with a large pelvic abscess overriding the uterine fundus. Sonography and magnetic resonance imaging confirmed the presence of the unusual pelvic abscess and, in addition, noted findings consistent with perforation of the uterus during endometrial sampling.

Mature cystic teratoma of the sigmoid colon

A 38-year-old woman, gravida 4 para 2, was followed at the State University of New York (SUNY), Downstate Medical Center, during her current pregnancy. Her medical history was unremarkable other than asymptomatic bilateral ovarian dermoid cysts documented sonographically prior to pregnancy, for which she declined surgical management. She denied any history of pelvic pain. Her pregnancy was uneventful but, because of fetal macrosomia, she elected to undergo primary Cesarean delivery at term with concurrent bilateral resection of the dermoid cysts. A male infant weighing 4200 g was delivered through a transverse lower segment uterine incision. Apgar scores were 9 and 9 at 1 and 5 min, respectively. Dense pelvic adhesions were encountered. Bilateral ovarian cystectomy (left and right cysts measuring 10 × 7 × 4 cm and 8.5 × 8 × 4 cm, respectively), was performed without difficulty. The sigmoid colon was inseparable from the right utero-ovarian ligament, yet distinctly separate from the right ovary, and contained a palpable solid intraluminal mass measuring 5 cm. Due to the suspicion of gastrointestinal malignancy, resection of the sigmoid colon containing this mass was performed with end-to-end anastomosis. Pathological examination of the resected sigmoid colon demonstrated a 5-cm mature cystic teratoma (containing hair and a tooth) within the lumen and in continuation with its wall (Figure 1). The patient’s postoperative course was unremarkable, and both mother and infant were discharged in good health on postoperative day 6. Distinctive sonographic features of mature cystic teratomas of the ovary include the presence of highly

Transvaginal sonography of postabortal (redo) syndrome

Acute hematometra, also termed the postabortal syndrome or redo syndrome, is a rare immediate complication of suction curettage characterized by severe lower abdominal cramping in association with an enlarged and markedly tender uterus. We describe the transvaginal sonographic features of this syndrome.

Sonographic and multiplanar computed tomographic findings of large uterine perforation 2 weeks after first-trimester pregnancy termination.

Perforation of the uterus usually results from either iatrogenic or, less frequently, spontaneous occurrences. 1-6 Iatrogenic etiologies include perforations occurring during dilation and curettage, hysteroscopy, and insertion of intrauterine contraceptive devices or brachytherapy tandems or as a result of endometrial ablation. 1-3 Spontaneous etiologies include pyometra, gestational trophoblastic disease, placenta accreta, and rarely degeneration of a myoma and uterine infarction. 3-6 Procedure-related uterine perforation is usually considered and diagnosed clinically at the time of injury, hence the relative sparse literature pertaining to imaging findings associated with uterine perforation. We report an unusual case in which uterine perforation was confirmed by sonography and computed tomography 2 weeks after pregnancy termination at 13 weeks gestation.

Sonographic and Magnetic Resonance Imaging of a Massive Epidermoid Cyst of the Pelvis and Buttock

Germ cell tumors are most commonly located within the gonads. 1 Rare extragonadal locations of these tumors include the retroperitoneum, mediastinum, sacrococcygeum, and central nervous system and are considered to result from aberrant migration of germ cells from the yolk sac during fetal development. 1―4 We present transvaginal sonographic and magnetic resonance imaging (MRI) findings of a massive epidermoid cyst extending from the pelvis to the buttock.