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Amylase-containing ovarian cystadenocarcinoma simulating a pancreatic pseudocyst
pyuria. and intrat,esical calculi following a MarshallI4archettLKrantz procedure are highly suggestive of inadvertent placement of permanent sutures into the lumen of the bladder. Cystoscopy will be diagnostic if the cause is the presence of intravesical sutures. These should bc resected transurethrally, for attempts at n-eating irritative bladder syrnptoms with antispasmedics tibiotics rvill be ineffectual until the fin-eign bodies arc removed. Some authors suggest that permanent sutures might be acceptable in a suspension when a transvesical or open-bladder approach is used, in which case, placernent of a suture through the bladder mucosa could be immediately recognized and corrected.. However, with permanent suture. one still risks potential morbidity from chrome osteitis pubis. \vhich is the most common major (complication occurring after bladder suspension 1, ith the ~~~~rs~~~lll-~~arc~~etti-~rant~ procedure. pcrriiancnt
suture
dots
not
make
a suspension
mot-e
permanent. The basis for the strength of the urethrovesk al suspension lies in the scarring and fixation of thr paraurethral l’ascia to the retropubis. Absorbable sutures
sinipl>
maintain
the vesical neck until
the
new
the patient’s
anatomic
position
own fibrous
of
tissue
forrnatio~~ U~Y LIVS and tahes over fLr the sutures.’ The conlplicatiorls folhnving the use of permanent SLI~UI-e for the Grshall-klarchetti-Krantz procedure fhl. out~~t+l~ an? potenrial advantages. Therefore. the use of rro~~~ll~sorb~~l~le suture cannot be justified. REFERENCES
1, Lapi&, J.: OperaGve techniyue fc)r stress urinary incominmce, Ilrologv 3: 657% 1974. 2. Marshall. V. F., Marchetti, A. A., and Krantz, K. E.: The correction of stress incontinence by simple vesicourethral stlspenGori, Surg. Gvnecol. ObsteL 88: 509, 1949.
Amylase-containing ovarian cystadenocarcinoma simulating a pancreatic pseudocyst
implicating liver as an ~-a~nylase-s~iitli(,si/iii~~ organ,’ this has been proved definitiveI! only ti)l the rat. In human subjects, Fallopian tubes have hecn shown to contain the enzyme and high serum amvlase lt~~ls arc sometimes associated with Fallopian tilhis p;~thology.2 It is not widely appreciated that humail ovaries also ma> contain amvlase. We recently encounferefl a patient with cystadenocar&oma of the oval-v <<*staining liui(f with extremely high amylase levels. A 77-year-old white wornan \vas referred to its for treatment of intractable ascites. She had noted a lnarked increase in abdominal girth over the last 2 years. but denied all other symptoms. Her past history F\rasessentially unremarkable. On physical examination, the abdomen was extremeI>, promberant with a prominent venous pat~crn radiating from the midline. Shifting dullness was t>otcd throughout the abdomen with a positive fluid wa\‘e. Pelvic examination show-ed a freely movable uterus with appat-entlv clear xincxal areas. The ovaries \vere not palpatecl. Initial laboratory finding; i&luded: whiith blood count, 11,600 per cubic millimeter; hemoglobin, 13.0 (inI. per 1Ofl ml.: hematocrit, 39. I per cent; blood urea niil-ogcn. 2.5 rng. per 100 ml.; fasting blood sugar, l 15 mg. pear. IO0 ml.; sodium, 141 mEq. per liter; potassium, 4.1 l~lE(l. per liter; calcium, 8.4 mg. per 100 ml.: phosphorus. .>.5 nag. per 100 ml.; serum glutamine pyruvic transamina5r. I.7 1 ‘, per milliiiter; lactic dehydrogenase, I60 U. per millilitc~ : bilirubin, 0.7 mg. per IO0 ml.: albumin, 4.4 Gm. per 100 ml.; globulins. 2.2 Gm. per IO0 ml.; prothrombin time. tOO p NXS negative. Speciftc gravit! , I .08 I ; protein. 12.8 Ch. pet- IWI ml.; albu-
min. 7.92 Gm. per 100 ml.; alpha, beta, and ga~nma globulins, 1.76, 1.71, dnd I.38 Gm. per IO0 ml.: calcium II.5 mg, pa 100 ml.; phosphorus, 0.5 mg. per 100 ml.: lactic dehydrogenase, 280 r. per milliliter: amylasc, 7,050 I’. pej’ milliliter. A technetium-99 liver-spleen scan r~as ititerprcted a$ xbnormal. with diffuse hepatocellular disease and splenomegaly. An ukrasonic echogram of the abdomet~ ~h~~wed a targe, fluid-filled cavity, with displacement of tn~)~~*II the gas-tilled bowel to the upper abdomen, leading to an :mpressioll of a massive intra-abdominal fluid c&ecGon, prf hat+ ascites. Selective sptenic and pelvic arteriograph! showed uptvard stretching and displacement of ihe distal br;tnc~hes of the superior mesenteric artery suggestive of an oval?afl or meserlteric cyst. Upper gastroimesGna1 serieh c~~lcl small bo\\el follow-through showed a normal esophagus and duodcm~~rn, but displacement of the entire small bowel illto the upper
abdomen. Intravenous
S ‘4 I, i v A R I’ glands and pancreas are the conventionally accepted sources of amvlase. While there is evidence This research was supported in part by the Medical Staff Research and Education Fund of Wayne County General IIospiml, Floisc, Michigan. Reprint requests: Dr. R. R. Joseph, Department of Medicine, Wayne County General Hospital, P.O. Box 124, Eloise, Michigan 48 132.
pyelogram
showed a 1‘11ge
sr~~un~
of
abdominal fluid. minimally dilated ul-ctcrs, ‘~nd extensive compression of the teft la&al superior. portioji (11 the bladder. Exploratory laparommy was performed :\lmost immediately upon entering die perimncal cavirv. a massive ovarian cyst was encountered. A supracervicat hysterectomy and bilateral salpingo-oophorecmmy 1%ere 1,~ termed. ‘ik right ovarian cystic mass was a ~~,ell-diff~r~riti~lt~~~l papillary serous c~sta~Ien(~c~trciii(~rn~~.
The suggested
high amylase that
ovaries
activity might
in the ~~\‘ar~arl cyst fluid inhei-<*ntl\
<.ontain
the
enzyme. Consequently the amylase from the cyst fluid, concentrated and partially purified by gel chromatography, was compared by disc gel electrophoresis with amylase extracted, purified, and concentrated from an ovary excised from a patient with pelvic inflammatory disease. Alpha-amylase activity of the initial ovarian homogenate was 9,2 U.* for 107 mg. of protein, well in excessof any value attributable to residual blood. After partial purification and concentration, a specific activity of 5.05 U.* per milligram of protein was attained. The ovarian cyst fluid from the patient, similarly purified and concentrated, yielded an o-amylase fraction with a specific activity of 1% LJ.* per milligram of protein. No increase in reducing groups was observed when the two purified preparations were incubated with maltose, confirming that the observed hydrolytic activity was that of an o-amylase. Disc gel electrophoresis, pH 8.8, demonstrated three isoenzymes. A single band with Rt= 0.03, presumably *One unit of amylase activity was defined as the production of 1 /AM of maltose reducing equivalents per minute from soluble starch at 37O C. at pH 7.0.
corresponding to one isoamylase, was obtained for the ovarian cyst preparation; the ovary yielded two isoamylases, a major component of Rr = 0.26 and a minor component with Rr = 0.09. The difference in isoenzyme composition between the two preparations was ascribed to the fact that they were obtained from two different individuals with unrelated diseases, one of which involved a neoplasm. A recent study’ suggested that elevated serum amylase levels might be used to differentiate Fallopian tube from ovarian lesions. Cur studies indicate that human ovaries probably also produce amylase. Thus, an elevated amylase ievel in serum, cyst fluid, or peritoneal fluid cannot exclude the ovary as the site of abnormalitv. Thanks are due to Mr. Gary Foster for his excellent technical assistance. REFERENCES
1. Joseph, FL R., Olivero, E., and Ressler,N.: Electrophoretic study of human isoamylases, Gastroenterology 51: 377, 1966. 2. Hochberg, C. J.: Tubal amylase, Obstet. Gynecol. 43: 129% 1974.
suture
dots
not
make
a suspension
mot-e
permanent. The basis for the strength of the urethrovesk al suspension lies in the scarring and fixation of thr paraurethral l’ascia to the retropubis. Absorbable sutures
sinipl>
maintain
the vesical neck until
the
new
the patient’s
anatomic
position
own fibrous
of
tissue
forrnatio~~ U~Y LIVS and tahes over fLr the sutures.’ The conlplicatiorls folhnving the use of permanent SLI~UI-e for the Grshall-klarchetti-Krantz procedure fhl. out~~t+l~ an? potenrial advantages. Therefore. the use of rro~~~ll~sorb~~l~le suture cannot be justified. REFERENCES
1, Lapi&, J.: OperaGve techniyue fc)r stress urinary incominmce, Ilrologv 3: 657% 1974. 2. Marshall. V. F., Marchetti, A. A., and Krantz, K. E.: The correction of stress incontinence by simple vesicourethral stlspenGori, Surg. Gvnecol. ObsteL 88: 509, 1949.
Amylase-containing ovarian cystadenocarcinoma simulating a pancreatic pseudocyst
implicating liver as an ~-a~nylase-s~iitli(,si/iii~~ organ,’ this has been proved definitiveI! only ti)l the rat. In human subjects, Fallopian tubes have hecn shown to contain the enzyme and high serum amvlase lt~~ls arc sometimes associated with Fallopian tilhis p;~thology.2 It is not widely appreciated that humail ovaries also ma> contain amvlase. We recently encounferefl a patient with cystadenocar&oma of the oval-v <<*staining liui(f with extremely high amylase levels. A 77-year-old white wornan \vas referred to its for treatment of intractable ascites. She had noted a lnarked increase in abdominal girth over the last 2 years. but denied all other symptoms. Her past history F\rasessentially unremarkable. On physical examination, the abdomen was extremeI>, promberant with a prominent venous pat~crn radiating from the midline. Shifting dullness was t>otcd throughout the abdomen with a positive fluid wa\‘e. Pelvic examination show-ed a freely movable uterus with appat-entlv clear xincxal areas. The ovaries \vere not palpatecl. Initial laboratory finding; i&luded: whiith blood count, 11,600 per cubic millimeter; hemoglobin, 13.0 (inI. per 1Ofl ml.: hematocrit, 39. I per cent; blood urea niil-ogcn. 2.5 rng. per 100 ml.; fasting blood sugar, l 15 mg. pear. IO0 ml.; sodium, 141 mEq. per liter; potassium, 4.1 l~lE(l. per liter; calcium, 8.4 mg. per 100 ml.: phosphorus. .>.5 nag. per 100 ml.; serum glutamine pyruvic transamina5r. I.7 1 ‘, per milliiiter; lactic dehydrogenase, I60 U. per millilitc~ : bilirubin, 0.7 mg. per IO0 ml.: albumin, 4.4 Gm. per 100 ml.; globulins. 2.2 Gm. per IO0 ml.; prothrombin time. tOO p
min. 7.92 Gm. per 100 ml.; alpha, beta, and ga~nma globulins, 1.76, 1.71, dnd I.38 Gm. per IO0 ml.: calcium II.5 mg, pa 100 ml.; phosphorus, 0.5 mg. per 100 ml.: lactic dehydrogenase, 280 r. per milliliter: amylasc, 7,050 I’. pej’ milliliter. A technetium-99 liver-spleen scan r~as ititerprcted a$ xbnormal. with diffuse hepatocellular disease and splenomegaly. An ukrasonic echogram of the abdomet~ ~h~~wed a targe, fluid-filled cavity, with displacement of tn~)~~*II the gas-tilled bowel to the upper abdomen, leading to an :mpressioll of a massive intra-abdominal fluid c&ecGon, prf hat+ ascites. Selective sptenic and pelvic arteriograph! showed uptvard stretching and displacement of ihe distal br;tnc~hes of the superior mesenteric artery suggestive of an oval?afl or meserlteric cyst. Upper gastroimesGna1 serieh c~~lcl small bo\\el follow-through showed a normal esophagus and duodcm~~rn, but displacement of the entire small bowel illto the upper
abdomen. Intravenous
S ‘4 I, i v A R I’ glands and pancreas are the conventionally accepted sources of amvlase. While there is evidence This research was supported in part by the Medical Staff Research and Education Fund of Wayne County General IIospiml, Floisc, Michigan. Reprint requests: Dr. R. R. Joseph, Department of Medicine, Wayne County General Hospital, P.O. Box 124, Eloise, Michigan 48 132.
pyelogram
showed a 1‘11ge
sr~~un~
of
abdominal fluid. minimally dilated ul-ctcrs, ‘~nd extensive compression of the teft la&al superior. portioji (11 the bladder. Exploratory laparommy was performed :\lmost immediately upon entering die perimncal cavirv. a massive ovarian cyst was encountered. A supracervicat hysterectomy and bilateral salpingo-oophorecmmy 1%ere 1,~ termed. ‘ik right ovarian cystic mass was a ~~,ell-diff~r~riti~lt~~~l papillary serous c~sta~Ien(~c~trciii(~rn~~.
The suggested
high amylase that
ovaries
activity might
in the ~~\‘ar~arl cyst fluid inhei-<*ntl\
<.ontain
the
enzyme. Consequently the amylase from the cyst fluid, concentrated and partially purified by gel chromatography, was compared by disc gel electrophoresis with amylase extracted, purified, and concentrated from an ovary excised from a patient with pelvic inflammatory disease. Alpha-amylase activity of the initial ovarian homogenate was 9,2 U.* for 107 mg. of protein, well in excessof any value attributable to residual blood. After partial purification and concentration, a specific activity of 5.05 U.* per milligram of protein was attained. The ovarian cyst fluid from the patient, similarly purified and concentrated, yielded an o-amylase fraction with a specific activity of 1% LJ.* per milligram of protein. No increase in reducing groups was observed when the two purified preparations were incubated with maltose, confirming that the observed hydrolytic activity was that of an o-amylase. Disc gel electrophoresis, pH 8.8, demonstrated three isoenzymes. A single band with Rt= 0.03, presumably *One unit of amylase activity was defined as the production of 1 /AM of maltose reducing equivalents per minute from soluble starch at 37O C. at pH 7.0.
corresponding to one isoamylase, was obtained for the ovarian cyst preparation; the ovary yielded two isoamylases, a major component of Rr = 0.26 and a minor component with Rr = 0.09. The difference in isoenzyme composition between the two preparations was ascribed to the fact that they were obtained from two different individuals with unrelated diseases, one of which involved a neoplasm. A recent study’ suggested that elevated serum amylase levels might be used to differentiate Fallopian tube from ovarian lesions. Cur studies indicate that human ovaries probably also produce amylase. Thus, an elevated amylase ievel in serum, cyst fluid, or peritoneal fluid cannot exclude the ovary as the site of abnormalitv. Thanks are due to Mr. Gary Foster for his excellent technical assistance. REFERENCES
1. Joseph, FL R., Olivero, E., and Ressler,N.: Electrophoretic study of human isoamylases, Gastroenterology 51: 377, 1966. 2. Hochberg, C. J.: Tubal amylase, Obstet. Gynecol. 43: 129% 1974.