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Computerized tomography in cases of lipoid cell tumor causing virilization
684 Correspondence
gnomonic for ectopic pregnancy. Our data shows that a rise or a fall in the serum hCG of 20% or less over a 48-hour period has so far had a 100% predictive value for an ectopic pregnancy (Kadar N, Romero R. Further observations on serial serum hCG patterns in ectopic pregnancies and abortions. Unpublished observations.) (Approximately 30% of ectopics will be associated with this pattern.) Titers of hCG that fall at a greater rate can be associated with either some type of abortion or an ectopic pregnancy, so curettage can be helpful. However, if the serum hCG is under 1000 to 1500 mIU/ml, and the serum hCG falls by more than 50% after 48 hours, there is a high chance that curettage will not yield chorionic villi. Not all of our patients falling into this category were subjected to a laparoscopy, so the possibility that some of them had resorbing ectopic pregnancies remains. However, we have had experience of six additional cases in which laparoscopy for failure to obtain villi at curettage, coupled with a positive hCG assay result, did not reveal the presence of an ectopic pregnancy. Private conversations with colleagues have revealed that they too have had personal experiences of such a situation. Do such cases represent false positives in the sense implied by Landesman et al. (that is, a positive result in patients that were not pregnant at all) or simply the dissolution of the villi of a dead pregnancy and/or the failure to retrieve villi by curettage in very early pregnancies? We are aware of only two patients in the last 5 years of hCG testing in our institution who had a positive assay result and who had not had either confirmation of a pregnancy (sonographic, clinical, or histologic) or serial hCG determinations until the titers fell to undetectable levels (barring cases of trophoblastic diseases). We must therefore conclude that the false positive assay, with use of such a definition, is extremely small. These two patients were called to our attention by practicing colleagues, because they had persistently positive low hCG titers and therefore fell into the category of "discordant hCG results." The nature of this problem has been discussed in detail by Hussa et al. '7 Roberto Romero, M.D. Nicholas Kadar, M.A. Section of Maternal-Fetal Medicine Department of Obstetrics and Gynecology Yale University School of Medicine 339 FMB P. O. Box 3333 New Haven, Connecticut 06510-8063
REFERENCES 1. Kadar N, DeVore G, Romero R. Discriminatory hCG zone: its use in the sonographic evaluation for ectopic pregnancy. Obstet Gynecol 1981;58:156. 2. Kadar N, Caldwell B V, Romero R. A method of screening for ectopic pregnancy and its indications. Obstet Gynecol 1981;58:162. 3. Kadar N, DeCherney AH, Romero R. Receiver operating characteristic (ROC) curve analysis of the relative efficacy of single and serial chorionic gonadotropin determina-
September 1986 Am J Obstet Gynecol
4.
5. 6.
7.
8. 9. 10. 11.
12.
13.
14.
15.
16. 17.
tions in the early diagnosis of ectopic pregnancy. Fertil Steril 1982;37:542. Kadar N, Taylor KW, Rosenfield AT, Romero R. Combined use of chorionic gonadotropin beta-subunit assay and ultrasound in the evaluation for ectopic pregnancy. Am J Roentgenol 1983; 141:609. Kadar N, Romero R. Timing of a repeat ultrasound examination in the evaluation for ectopic pregnancy. J Clin Ultrasound 1982;10:403. Kadar N. Ectopic pregnancy: a reapproach of etiology diagnosis and treatment. In: John Stodd, ed. Progress in obstetrics and gynecology. vol3. pp 305. New York: Churchill Livingstone, 1983;305. Romero R, Kadar N,Jeanty P, Cope1JA, DeCherney AH, Hobbins JC. The diagnosis of ectopic pregnancy: the value of the discriminatory hCG zone. Obstet Gynecol 1985;65:519. Chard T, Norman RJ, Lowings C. Dipstick method for human chorionic gonadotropin suitable for emergency use on whole blood and other fluids. Lancet 1985; 1: 19. Marshall JR, Hammond CB, Ross GT, et al. Plasma and urinary chorionic gonadotropin during early human pregnancy. Obstet Gynecol 1968;32:760. Lagrew DC, Wilson EA,Jawad MJ. Determination of gestational age by serum concentrations of human chorionic gonadotropin. Obstet Gynecol 1983;62:37. Pitta way DE, Reish RL, Wentz AC. Doubling times of human chorionic gonadotropin increase in early viable intrauterine pregnancies. AM J OSSTET GYNECOL 1985; 152:299. Kadar N. Relationship between log of the human chorionic gonadotropin concentration and time period in early pregnancy [Letter to the Editor]. AM J OSSTET GYNECOL 1986; 154:692. Mishell DR, Nakamura RM, Barberia JM, et al. Initial detection of human chorionic gonadotropin in serum in normal human gestation. AM J Os STET GYNECOL 1976; 118:990. Sandvei R, Stoa KF, Ulstein M. Radioimmunoassay of human chorionic gonadotropin beta-subunit as an early diagnostic test in ectopic pregnancy. Acta Obstet Gynecol Scand 1981;60:389. Kadar N. The combined use of grey-scale ultrasound and a quantitative radioimmunoassay for serum hCG in the diagnosis of ectopic pregnancy [Prize Paper]. Boston: Boston Obstetrical Society, 1981. Romero R. Understanding and treating first trimester vaginal bleeding. Contemp OB/GYN 1983;21:45. Hussa RO, Rinek ML, Schewitzer PG. Discordant human chorionic gonadotropin results: causes and solutions. Obstet Gynecol 1985;65:21.
Computerized tomography in cases of lipoid cell tumor causing virilization To the Editors: I am writing in reference to the article "Steroid secretion by a lipoid cell tumor causing virilization and its diagnosis with computerized tomography" by Fonseca et al. (AM J OB5TET GYNECOL 1985;153:797-8). I am perplexed by the emphasis in this article on the use of computerized tomography. It appears from the case report that the correct diagnosis and the indications for surgery did not involve the performance of a computerized tomographic scan. The findings of a dramatically elevated peripheral testosterone level and left ovarian enlargement on ultrasound were sufficient indication for laparotomy without other confirmatory, expensive radiographic studies. Indeed, had the left adnexal mass
Correspondence 685
Volume 155 Number 3
been palpable on examination, even the ultrasound would have been redundant. In addition, I must assume from the postoperative laboratory values that the treatment involved bilateral oophorectomy, presumably with hysterectomy and bilateral salpingectomy. If precise localization of the tumor site by computerized tomographic scan was able to pinpoint the tumor, what was the indication for a bilateral oophorectomy? In a time when the watchword for American medicine is cost containment, we must all guard against the temptation to perform unnecessary and expensive diagnostic tests. A virilized patient with an elevated peripheral testosterone level and an adnexal mass does not need a computerized tomographic scan. George M. Grunert, M.D. Obstetrical and Gynecological Associates 7550 Fannin Street Houston, Texas 77054
Reply To the Editors: The diagnosis of virilizing ovarian tumor is frequently misleading; therefore it was a common procedure to perform a laparoscopy in order to establish the definitive diagnosis in those cases of severe virilization. We believe that the clinical and biochemical features associated with ovarian enlargement proved either on ultrasound or computerized tomographic scan are necessary to indicate the surgical approach. A small adnexal mass on pelvic examination may be deceiving, so that the confirmation by ultrasound or x-ray film is not redundant. The indication for bilateral oophorectomy in this case was the polycystic appearance of the contralateral ovary at the time of laparotomy. Arturo Zarate, M.D. Apdo. Postal 107-115 06760 Mexico, D.F.
Prophylactic posterior culdoplasty To the Editors: In his recent article (AM J OBSTET GVNECOL 1985; 153: 135-9) Dr. Given very convincingly stressed the point that when a uterine prolapse is associated with a sizable enterocele, a well-executed posterior culdoplasty (either by McCall's or Torpin's technique) is a most important and integral part of the operation of vaginal hysterectomy. Unfortunately, the article has left the impression, which I must take issue with, that when the uterine prolapse is not associated with an overt enterocele, the performance of a prophylactic posterior culdoplasty at the time of the vaginal hysterectomy may be omitted. The great master of abdominopelvic surgery, Victor Bonney, had taught that meticulous pelvic floor repair and vaginal vault suspension are most important integral parts of the operation of vaginal hysterectomy for uterine prolapse, even in the absence of an asso-
ciated overt enterocele. l This is done to prevent later posthysterectomy development of an enterocele and vaginal vault prolapse. Thus, residents in training should be taught to think first of the pelvic floor repair that is associated with vaginal hysterectomy for uterine prolapse even in the absence of an enterocele, instead of thinking first of the removal of the uterus. I prefer personally in the performance of prophylactic posterior culdoplasty the technique which has been described by McCaW and has so nicely been demonstrated in TeLinde's Operative Gynecology.3 I use a modification in which the strands of the previously placed retention sutures on the pedicles of the sacrouterine ligaments are used for the performance of the prophylactic posterior culdoplasty and the suspension of the vaginal vault. Benjamin Piura, M.D. Division of Obstetrics and Gynecology Soroka University Hospital Faculty of Health Sciences Ben-Gurion University of the Negev P. O. Box 151 Beer-Sheva 84101, Israel REFERENCES 1. Hawkins J, Stall worthy J. Bonney's Gynaecological Surgery. 8th ed. London: Bailliere Tindall, 1974:492-547. 2. McCall ML. Posterior culdoplasty. Obstet Gynecol 1957; 10:595-602. 3. Mattingly RF, Thompson JD. TeLinde's Operative Gynecology. 6th ed. Philadelphia: JB Lippincott, 1985:548-559.
Reply To the Editors: In reply to Dr. Piura, I feel that I must indeed take issue with him in interpreting my article as giving the impression of a lack of interest in prophylactic culdoplasty at the time of hysterectomy. The purpose was to give the technique and some long-term results with use of two types of culdoplasties in more difficult situations, that is, moderate to large enteroceles and even complete vagina eversion in patients wishing to maintain sexual function. In my article on page 136, it was stated 'The McCall stitch was recommended by both the Mayo Clinic Group and in TeLinde and Mattingly'S Operative Gynecology to be used prophylactically at the time of vaginal hysterectomy." Indeed, I frequently use these techniques at the time of vaginal hysterectomy and personally highly recommend them. However, it would be extremely difficult to prove their effectiveness without a large doubleblind study. Waters l in 1956 reports one failure in 48 cases with wedge culdoplasty as compared to 14 recurrences of cystocele, enterocele, and/or vault prolapse in 210 vaginal hysterectomies without his technique. He also called attention to the use of posterior vault excision at the time of abdominal hysterectomy. Since almost half of the cases of posthysterectomy, enterocele, and/or prolapse of the vaginal vault follow abdominal hysterectomy, it would seem that some type of pro-
gnomonic for ectopic pregnancy. Our data shows that a rise or a fall in the serum hCG of 20% or less over a 48-hour period has so far had a 100% predictive value for an ectopic pregnancy (Kadar N, Romero R. Further observations on serial serum hCG patterns in ectopic pregnancies and abortions. Unpublished observations.) (Approximately 30% of ectopics will be associated with this pattern.) Titers of hCG that fall at a greater rate can be associated with either some type of abortion or an ectopic pregnancy, so curettage can be helpful. However, if the serum hCG is under 1000 to 1500 mIU/ml, and the serum hCG falls by more than 50% after 48 hours, there is a high chance that curettage will not yield chorionic villi. Not all of our patients falling into this category were subjected to a laparoscopy, so the possibility that some of them had resorbing ectopic pregnancies remains. However, we have had experience of six additional cases in which laparoscopy for failure to obtain villi at curettage, coupled with a positive hCG assay result, did not reveal the presence of an ectopic pregnancy. Private conversations with colleagues have revealed that they too have had personal experiences of such a situation. Do such cases represent false positives in the sense implied by Landesman et al. (that is, a positive result in patients that were not pregnant at all) or simply the dissolution of the villi of a dead pregnancy and/or the failure to retrieve villi by curettage in very early pregnancies? We are aware of only two patients in the last 5 years of hCG testing in our institution who had a positive assay result and who had not had either confirmation of a pregnancy (sonographic, clinical, or histologic) or serial hCG determinations until the titers fell to undetectable levels (barring cases of trophoblastic diseases). We must therefore conclude that the false positive assay, with use of such a definition, is extremely small. These two patients were called to our attention by practicing colleagues, because they had persistently positive low hCG titers and therefore fell into the category of "discordant hCG results." The nature of this problem has been discussed in detail by Hussa et al. '7 Roberto Romero, M.D. Nicholas Kadar, M.A. Section of Maternal-Fetal Medicine Department of Obstetrics and Gynecology Yale University School of Medicine 339 FMB P. O. Box 3333 New Haven, Connecticut 06510-8063
REFERENCES 1. Kadar N, DeVore G, Romero R. Discriminatory hCG zone: its use in the sonographic evaluation for ectopic pregnancy. Obstet Gynecol 1981;58:156. 2. Kadar N, Caldwell B V, Romero R. A method of screening for ectopic pregnancy and its indications. Obstet Gynecol 1981;58:162. 3. Kadar N, DeCherney AH, Romero R. Receiver operating characteristic (ROC) curve analysis of the relative efficacy of single and serial chorionic gonadotropin determina-
September 1986 Am J Obstet Gynecol
4.
5. 6.
7.
8. 9. 10. 11.
12.
13.
14.
15.
16. 17.
tions in the early diagnosis of ectopic pregnancy. Fertil Steril 1982;37:542. Kadar N, Taylor KW, Rosenfield AT, Romero R. Combined use of chorionic gonadotropin beta-subunit assay and ultrasound in the evaluation for ectopic pregnancy. Am J Roentgenol 1983; 141:609. Kadar N, Romero R. Timing of a repeat ultrasound examination in the evaluation for ectopic pregnancy. J Clin Ultrasound 1982;10:403. Kadar N. Ectopic pregnancy: a reapproach of etiology diagnosis and treatment. In: John Stodd, ed. Progress in obstetrics and gynecology. vol3. pp 305. New York: Churchill Livingstone, 1983;305. Romero R, Kadar N,Jeanty P, Cope1JA, DeCherney AH, Hobbins JC. The diagnosis of ectopic pregnancy: the value of the discriminatory hCG zone. Obstet Gynecol 1985;65:519. Chard T, Norman RJ, Lowings C. Dipstick method for human chorionic gonadotropin suitable for emergency use on whole blood and other fluids. Lancet 1985; 1: 19. Marshall JR, Hammond CB, Ross GT, et al. Plasma and urinary chorionic gonadotropin during early human pregnancy. Obstet Gynecol 1968;32:760. Lagrew DC, Wilson EA,Jawad MJ. Determination of gestational age by serum concentrations of human chorionic gonadotropin. Obstet Gynecol 1983;62:37. Pitta way DE, Reish RL, Wentz AC. Doubling times of human chorionic gonadotropin increase in early viable intrauterine pregnancies. AM J OSSTET GYNECOL 1985; 152:299. Kadar N. Relationship between log of the human chorionic gonadotropin concentration and time period in early pregnancy [Letter to the Editor]. AM J OSSTET GYNECOL 1986; 154:692. Mishell DR, Nakamura RM, Barberia JM, et al. Initial detection of human chorionic gonadotropin in serum in normal human gestation. AM J Os STET GYNECOL 1976; 118:990. Sandvei R, Stoa KF, Ulstein M. Radioimmunoassay of human chorionic gonadotropin beta-subunit as an early diagnostic test in ectopic pregnancy. Acta Obstet Gynecol Scand 1981;60:389. Kadar N. The combined use of grey-scale ultrasound and a quantitative radioimmunoassay for serum hCG in the diagnosis of ectopic pregnancy [Prize Paper]. Boston: Boston Obstetrical Society, 1981. Romero R. Understanding and treating first trimester vaginal bleeding. Contemp OB/GYN 1983;21:45. Hussa RO, Rinek ML, Schewitzer PG. Discordant human chorionic gonadotropin results: causes and solutions. Obstet Gynecol 1985;65:21.
Computerized tomography in cases of lipoid cell tumor causing virilization To the Editors: I am writing in reference to the article "Steroid secretion by a lipoid cell tumor causing virilization and its diagnosis with computerized tomography" by Fonseca et al. (AM J OB5TET GYNECOL 1985;153:797-8). I am perplexed by the emphasis in this article on the use of computerized tomography. It appears from the case report that the correct diagnosis and the indications for surgery did not involve the performance of a computerized tomographic scan. The findings of a dramatically elevated peripheral testosterone level and left ovarian enlargement on ultrasound were sufficient indication for laparotomy without other confirmatory, expensive radiographic studies. Indeed, had the left adnexal mass
Correspondence 685
Volume 155 Number 3
been palpable on examination, even the ultrasound would have been redundant. In addition, I must assume from the postoperative laboratory values that the treatment involved bilateral oophorectomy, presumably with hysterectomy and bilateral salpingectomy. If precise localization of the tumor site by computerized tomographic scan was able to pinpoint the tumor, what was the indication for a bilateral oophorectomy? In a time when the watchword for American medicine is cost containment, we must all guard against the temptation to perform unnecessary and expensive diagnostic tests. A virilized patient with an elevated peripheral testosterone level and an adnexal mass does not need a computerized tomographic scan. George M. Grunert, M.D. Obstetrical and Gynecological Associates 7550 Fannin Street Houston, Texas 77054
Reply To the Editors: The diagnosis of virilizing ovarian tumor is frequently misleading; therefore it was a common procedure to perform a laparoscopy in order to establish the definitive diagnosis in those cases of severe virilization. We believe that the clinical and biochemical features associated with ovarian enlargement proved either on ultrasound or computerized tomographic scan are necessary to indicate the surgical approach. A small adnexal mass on pelvic examination may be deceiving, so that the confirmation by ultrasound or x-ray film is not redundant. The indication for bilateral oophorectomy in this case was the polycystic appearance of the contralateral ovary at the time of laparotomy. Arturo Zarate, M.D. Apdo. Postal 107-115 06760 Mexico, D.F.
Prophylactic posterior culdoplasty To the Editors: In his recent article (AM J OBSTET GVNECOL 1985; 153: 135-9) Dr. Given very convincingly stressed the point that when a uterine prolapse is associated with a sizable enterocele, a well-executed posterior culdoplasty (either by McCall's or Torpin's technique) is a most important and integral part of the operation of vaginal hysterectomy. Unfortunately, the article has left the impression, which I must take issue with, that when the uterine prolapse is not associated with an overt enterocele, the performance of a prophylactic posterior culdoplasty at the time of the vaginal hysterectomy may be omitted. The great master of abdominopelvic surgery, Victor Bonney, had taught that meticulous pelvic floor repair and vaginal vault suspension are most important integral parts of the operation of vaginal hysterectomy for uterine prolapse, even in the absence of an asso-
ciated overt enterocele. l This is done to prevent later posthysterectomy development of an enterocele and vaginal vault prolapse. Thus, residents in training should be taught to think first of the pelvic floor repair that is associated with vaginal hysterectomy for uterine prolapse even in the absence of an enterocele, instead of thinking first of the removal of the uterus. I prefer personally in the performance of prophylactic posterior culdoplasty the technique which has been described by McCaW and has so nicely been demonstrated in TeLinde's Operative Gynecology.3 I use a modification in which the strands of the previously placed retention sutures on the pedicles of the sacrouterine ligaments are used for the performance of the prophylactic posterior culdoplasty and the suspension of the vaginal vault. Benjamin Piura, M.D. Division of Obstetrics and Gynecology Soroka University Hospital Faculty of Health Sciences Ben-Gurion University of the Negev P. O. Box 151 Beer-Sheva 84101, Israel REFERENCES 1. Hawkins J, Stall worthy J. Bonney's Gynaecological Surgery. 8th ed. London: Bailliere Tindall, 1974:492-547. 2. McCall ML. Posterior culdoplasty. Obstet Gynecol 1957; 10:595-602. 3. Mattingly RF, Thompson JD. TeLinde's Operative Gynecology. 6th ed. Philadelphia: JB Lippincott, 1985:548-559.
Reply To the Editors: In reply to Dr. Piura, I feel that I must indeed take issue with him in interpreting my article as giving the impression of a lack of interest in prophylactic culdoplasty at the time of hysterectomy. The purpose was to give the technique and some long-term results with use of two types of culdoplasties in more difficult situations, that is, moderate to large enteroceles and even complete vagina eversion in patients wishing to maintain sexual function. In my article on page 136, it was stated 'The McCall stitch was recommended by both the Mayo Clinic Group and in TeLinde and Mattingly'S Operative Gynecology to be used prophylactically at the time of vaginal hysterectomy." Indeed, I frequently use these techniques at the time of vaginal hysterectomy and personally highly recommend them. However, it would be extremely difficult to prove their effectiveness without a large doubleblind study. Waters l in 1956 reports one failure in 48 cases with wedge culdoplasty as compared to 14 recurrences of cystocele, enterocele, and/or vault prolapse in 210 vaginal hysterectomies without his technique. He also called attention to the use of posterior vault excision at the time of abdominal hysterectomy. Since almost half of the cases of posthysterectomy, enterocele, and/or prolapse of the vaginal vault follow abdominal hysterectomy, it would seem that some type of pro-