John L. Powell

Nd:YAG laser excision of a giant gingival pyogenic granuloma of pregnancy

A 19‐year‐old Hispanic nullipara experienced the rapid growth of an oral lesion on the right lower gingiva which she had first noticed at 29 weeks gestation. The lesion interfered with oral hygiene and eating. At surgery, the lesion measured 3.5 × 2.5 × 2.0 cm. Biopsy confirmed a pyogenic granuloma (“granuloma gravidarum”). Panorex films showed no bony invasion. The lesion was excised using the Nd:YAG laser under general anesthesia when the patient had reached 36 3/7 weeks gestation. We chose the Nd:YAG laser over the CO2 laser for the removal of this very vascular lesion, because of its superior coagulation characteristics. This technique results in removal of the lesion with less danger of bleeding than with any other surgical technique. The patient did well postoperatively, delivered a healthy 3,884 g infant at 40 6/7 weeks gestation, and has had no recurrence after 15 months of follow‐up.

Intermediate Filamentous Proteins in Adult Granulosa Cell Tumors: An Immunohistochemical Study of 25 Cases

Adult granulosa cell tumors (AGCTs) are classified as sex cord-stromal tumors of the ovary. However, they may be confused with other primary ovarian neoplasms. Intermediate filaments, specifically vimentin and cytokeratins, have been identified in AGCTs by immunohistochemistry performed on frozen and formalin-fixed, paraffinembedded tissue and two-dimensional electrophoresis. Recently, however, immunohistochemical demonstration of cytokeratin has been used as supporting evidence of epithelial rather than sex cord-stromal differentiation in ovarian neoplasia. To investigate further intermediate filamentous proteins in AGCTs, 25 such tumors were studied by immunohistochemistry in formalin-fixed, paraffinembedded sections. Cytoplasmic staining was observed, frequently in a distinct punctate, paranuclear pattern, in 14 of 25, 14 of 25, and seven of 17 tumors using monoclonal antibodies AE1/AE3, CAM 5.2, and 35BH11, respectively, which share the ability to detect low molecular weight cytokeratins. Staining for cytokeratin was not seen in any of the 17 tumors studied using the antibody 34BE12. Twenty-three of 25 tumors showed strong positivity for vimentin, characteristically seen as globoid paranuclear staining. Nine of 25 tumors contained desmin, which was restricted to the intermixed spindle cell, cortical type stromal component of the tumors. These patterns of immunoreactivity for intermediate filaments, particularly cytokeratins, are different than in common epithelial tumors of the ovary and may be useful in the differential diagnosis of ovarian neoplasia. Moreover, the immunohistochemical detection of cytokeratins should not be used as a criterion for excluding AGCT from the differential diagnosis of an ovarian neoplasm.

Management of Advanced Juvenile Granulosa Cell Tumor of the Ovary

Juvenile granulosa cell tumor of the ovary occurs most frequently in young women and children. Ten percent of cases present during pregnancy. The majority of tumors are in FIGO Stage I and have a favorable prognosis. The prognosis of higher stage tumors, however, is generally less favorable. We report the long-term, disease-free survival of a patient with FIGO Stage III juvenile granulosa cell tumor of the ovary. We believe this to be the first report of a successful pregnancy following MAC chemotherapy for this particular malignancy.

Ovarian serous borderline epithelial tumors with multiple retroperitoneal nodal involvement: Metastasis or malignant transformation of epithelial glandular inclusions?

One of four patients who underwent lymph node excision at exploration for ovarian serous borderline epithelial tumor (OSBT) at Baystate Medical Center was found to have FIGO Stage III C lesion associated with extensive ovarian external (surface) papillary growth, peritoneal implants in the omentum and cul-de-sac, and involvement of multiple pelvic and periaortic lymph nodes by the tumor. Histologically, the lymph nodes showed an admixture of endosalpingeal glandular inclusions with neoplastic tissue identical to the ovarian tumor. The exact histogenesis and the prognostic significance of the nodal involvement by OSBT are still not fully understood. Although there is a small number of reported cases of lymph node involvement associated with OSBT, they are described as examples of nodal metastases or independent primary foci of malignant transformation. This paper presents an interesting association of OSBT with extensive pelvic and periaortic nodal involvement and reviews the relevant literature.

Ovarian carcinoma metastatic to breast: A case report and review of the literature

Breast metastasis from ovarian carcinoma is a rare event, with only 26 cases being previously reported in the English literature. The twenty-seventh such case is presented herein, and the literature on this topic is reviewed. Metastases to the breast from the ovary signal widespread metastases and generally herald a rapid deterioration and death. Although rare, it is important that metastatic cancer to the breast be differentiated from primary breast carcinoma as both the treatment and prognosis differ significantly.

Radical hysterectomy and pelvic lymphadenectomy

In recent years there has been an increasing awareness that radical hysterectomy and pelvic lymphadenectomy can play an important role in the management of early invasive cervical cancer. We present a series of 255 patients who had radical hysterectomy for gynecologic malignancy over a nine-year period. The incidence of ureteral fistulas was 0.8% and of vesical fistulas 1.6%. The operative mortality was 0.78%, which compares favorably with the rates in most larger centers in which radical pelvic operations are common. With proper patient selection and excellent operative technique, survival rates of well over 90%, with minimal complications, can be obtained.

Cytoreductive Surgery for Ovarian Cancer With the Cavitron Ultrasonic Surgical Aspirator and the Development of Disseminated Intravascular Coagulation

Objective: To explore the association between the use of the Cavitron Ultrasonic Surgical Aspirator for cytoreduction of ovarian cancer and the intraoperative development of disseminated intravascular coagulation (DIC). Methods: A retrospective chart review was performed of all patients undergoing surgery for ovarian cancer from September 1991 to February 1993. Data were extracted to correlate clinical and hematologic evidence of DIC with and without intraoperative use of the Cavitron Ultrasonic Surgical Aspirator. Statistical analyses were done by X2 and analysis of variance. Results: Fifty‐one patients underwent surgery for ovarian cancer; 33 had stage IIIB, IIIC, IV, or recurrent disease and could be evaluated for this study. Nineteen patients were treated with the surgical aspirator, five of whom developed an intraoperative coagulopathy, as compared to none of 14 patients treated with conventional cytoreduction (P < .04, X2). The duration of use of the surgical aspirator correlated with the risk of coagulopathy (P < .001, analysis of variance). Conclusion: These data suggest a potential risk of developing DIC after extended use of the Cavitron Ultrasonic Surgical Aspirator for cytoreduction of ovarian cancer. (Obstet Gynecol 1994;83:1011‐4)

Hip disarticulation for recurrent vulvar cancer in the groin

Abstract A patient with squamous cell carcinoma of the vulva treated with a radical vulvectomy and bilateral inguinal and femoral lymphadenectomies utilizing separate groin incisions, subsequently developed a recurrence in the skin bridge between the vulvar and groin excisions. Following groin irradiation with chemosensitization, the tumor progressed to involve the superior pubic ramus and femoral vessels. A left hip disarticulation and resection of a portion of the superior pubic ramus was performed. The patient has been free of disease for 3 years. The advantages of this procedure over a hemipelvectomy include shorter operative time, reduced blood loss, better fascial closure of the abdomen, and the creation of a stump which is more amenable to prosthetic fitting.