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Ovarian malignancy subsequent to a Le Fort operation
210 Communications in brief
rate was found to be 85.7 per cent. It is our belief that clomiphene citrate therapy is preferable to treatment by wedge resection because: {1) a major operative procedure is avoided, (2) peritubal and periovarian adhesions frequently occur after wedge resection, and (3) the recurrence of anovulatory cycles following wedge resection is common. When clomiphene citrate successfully corrects the ovulatory defect, but pregnancy does not occur, two alternative methods of treatment have been recommended: combined clomiphene citrate-gonadotropin therapy and bilateral ovarian wedge resection. The former adds the risks of gonadotropin therapy and the latter substitutes potentially hazardous surgical therapy. The pregnancy rate following ovulation induced by these two methods has not been shown to be greater than that following ovulation induced by clomiphene citrate. The limitation of clomiphene citrate to an arbitrary number of apparently ovulatory cycles is not warranted in the absence of other infertility factors. If a patient ovulates, but does not conceive, cyclic clomiphene treatment should be continued. In this way patients may become pregnant with greater safety than after having a laparotomy and removal of functional ovarian tissue. As illustrated by this case report, when clomiphene citrate successfully induces ovulation, treatment should be continued until conception occurs. In this patient, treatment for more than 2 years had no deleterious effects and was followed by a successful pregnancy. REFERENCES
J. W.: In Behrman, S. J., and Kistner, R. W., editors: Progress in Infertility, Boston, 1968, Little, Brown & Company, p. 371. 2. Rust, L. A., Israel, R., and Mishell, D. R., Jr.: An individualized graduated therapeutic regimen for clomiphene citrate, AM. J. 0BSTET. GYNECOL. 1!0: 785, 1974.
January !5, 1976 Am . .J. Ohstel. Gynecol.
repair of uterine prolapse. Although the operation has been modified in several ways, the technique includes the denuding of rectangular areas of similar size on the anterior and posterior walls of the vagina and suturing these mucosal edges together and opposing the denuded surfaces so that drainage canals are created laterally, permitting the egress of uterine or cervical secretions. This procedure is usually restricted to those patients who are postmenopausal, are no longer interested in sexual activity, or have medical complications for which a rapid, noninvasive procedure is desirous. The major disadvantages of this procedure are that ( 1) intercourse is limited and (2) the facility for evaluation of postmenupausal bleeding is compromised. Postmenopausal bleeding subsequent to this procedure poses difficulty in diagnosis and often predisposes the gynecologist to suboptimal procedures, as well as hazardous delay. Dilatation and fractional curettage of the uterus may be precluded by vaginal obliteration and an abdominal hysterectomy may be required for diagnosis and treatment. In those cases with endometrial carcinoma, proper staging ·and review of histologic material was not carried out prior to surgery, compromising the patient's prognosis. In those cases where "breakdown" of the colpocleisis was successful and adequate diagnostic procedures were performed, the patient may be exposed to the risks of bladder and rectal injury. At New York Medical College~Metropolitan Medical Center, we recently encountered one patient who presented with complaint of postmenopausal bleeding 3 years following a Le Fort procedure.
l. Goldzieher,
Ovarian malignancy subsequent to a Le Fort operation NOROHITO SUDO, M.D. THEODORE GOLDBERG, M.D. SANFORD SALL, M.D. Gy'fUicologic Malignancy Service of the Department of Obstetrics and Gynecology, New York Medical College, New York, New York
THE LE FoRT colpocleisis is well known to gynecologists as a reliable procedure for the surgical Reprint requests: Sanford Sail, M.D., New York Medical College, Department of Obstetrics and Gynecology, 1249 Fifth Ave., New York, New York 10029.
J. G., a 56-year-old woman, gravida 3, para 3-0-0-3, whose last menstrual period was in 1965, was admitted on September 22, 1974, for evaluation of postmenopausal bleeding. Her past surgical history included a Le Fort colpocleisis in 1971 for uterine prolapse and cystorectocele. She had been well until June, 1974, when she noted small amounts of intermittent vaginal bleeding. She was seen in the gynecology clinic on July 26, 1974. Pelvic examination revealed no abnormalities other than an obliterated vagina; the Pap smear was Class II, showing mild atrophic atypia. The patient was admitted for a fractional dilatation and curettage. The cervix was approached by gradual dilatation of the right lateral drainage canal with lubricated Hegar dilators, as well as scalpel dissection of resistant fibrous bands. The previous surgery was not disrupted. The cervix was grasped, traction was applied, and fractional dilatation and curettage and cervical punch biopsies were performed. The pathology report revealed small amounts of moderately differentiated adenocarcinoma. Evaluation of metastatic sites of disease was negative. Our impression at that time was Stage Ia, Grade 2, endometrial carcinoma. Laparotomy revealed a 5 by 5 em. left adnexal mass with papillary seeding on the Fallopian tubes, the uterus, and the right ovary. There was diffuse seeding of tumor over the serosal surfaces of the small intestine and omentum. The liver, spleen, and kidneys were normal. A total abdominal hysterectomy and bilateral salpingo-oophorectomy and omentectomy were performed. Extirpation of the cervix was not hindered by the prior Le Fort procedure. The bulk of the tumor was removed, leaving diffuse small metastatic
Communications in brief 211
Volume 124 Number 2
Table I. Pelvic malignancy subsequent to aLe Fort procedure Authors, year, and no. of cases of malignancy in sems of LeFort operations
Mazer and Israel' (1948) l/43 Falk and Kaufman 1 (1955) l/100 Hanson and Keete!3 (1969) 1/288 Hanson and Keetel 3 ( 1969) Sudo, Goldberg, and Sail (1975)
l/74
Diagnostic method
Histology
Further treatment
TAH-BSO TAH D&C D&C, breakdown not mentioned D&C, no breakdown
Endometrial carcinoma Endometrial carcinoma Endometrial carcinoma Endometrial carcinoma
None None ICR* + T AH-BSO ICR
Ovarian carcinoma
T AH-BSO + external teletherapy
*Intracavitary radium. deposits. Surgical clips were placed in areas of larger metastatic concentrations. The pathology report revealed papillary adenocarcinoma of the left ovary. Postoperative cobalt-60 teletherapy was initiated on October 22, 1974 delivering 3,000 r to the whole abdomen in 4 weeks, given through AP-PA portals, blocking the kidneys posteriorly. This was followed by 2,000 r to the whole pelvis.
Pelvic malignancy following aLe Fort operation has been reported in only four instances, all of which have been endometrial in origin (Table 1). There are no reported cases of carcinoma of the cervix. 3 This is the first reported case of ovarian malignancy following a Le Fort colpocleisis. REFERENCES 1. Mazer, C., and Israel, S. L. : The Le Fort colpocleisis: An analysis of 43 operations, AM. J. OssTET. GYNECOL. 56: 944, 1948. 2. Falk, H . C., and Kaufman, S. Partial colpocleisis: The Le Fort procedure, Obstet. Gynecol. 5: 617, 1955. 3. Hanson, G. E., and Keetel, W. C.: The Neugebauer-Le Fort operation: A review of 288 colpocleises, Obstet. Gynecol. :J4: 352, 1969.
Benign melanosis of the vagina and cervix YOSHIAKI TSUKADA, M . D . Department of Pathology, Roswell Park Me1Mriallnstitulil, Buffalo, New York MELANOTIC lesions of the vagina and cervix, benign or malignant, are rare. The majority of such lesions should be regarded as malignant until proved otherwise, 1 but there are occasional benign cases. This report . illustrates a case of benign melanosis of the vagina and cervix in a 46-year-old woman which remained unchanged in a 13 year follow-up .
This 46-year-old black woman, gravida 4, para 2, abortus 2, was referred to this institute 13 years ago because of discoloration of the vaginal mucosa. She had had irregular Reprint requests: Yoshiaki Tsukada, M.D., Department of Pathology, Roswell Park Memorial Institute, Buffalo, New York 14203.
Fig. 1. Photomicrograph of the vaginal mucosa. (Section stained by Fontana stain for melanin; x220.) and heavy menstruation for the last 6 years and had been under the care of a physician, who noted the discoloration recently. On examination at this institute, irregular patches of bluish discoloration were noted on the vagina and portio vaginalis. The vaginal lesion was on the anterior wall, beginning at the right anterior fornix, and involved the upper two thirds of the vaginal canal, measuring about 3 em. in width. The area was neither raised nor firm and was normal on palpation. The cervical discoloration was noted at the 3 and 9 o'clock positions, each measuring about 0.7 em. Biopsies of the lesions revealed pigmentation of the basal layer of the squamous epithelium with melanin pigment. Melanocytes with dendrites and melanin pigment were evident among pigmented epithelial cells (Fig. 1). She has been followed at the outpatient clinic and the lesions have not changed. Another biopsy, obtained recently, showed the same histologic feature.
Benign melanotic lesions ofthe vagina and/or cervix are rare and only few cases have been documented . Nigogosyan, de la Pava, and Pickren 2 studied the vaginal mucosa of 100 random autopsies and found a similar lesion to that of the present case in three cases. All three patients were elderly white women. In one case the pigmentation was extensive. This patient received radiation to the uterus for postmenopausal bleeding 9 months before death. In the other two the pigmented areas were small. In none of the cases were
rate was found to be 85.7 per cent. It is our belief that clomiphene citrate therapy is preferable to treatment by wedge resection because: {1) a major operative procedure is avoided, (2) peritubal and periovarian adhesions frequently occur after wedge resection, and (3) the recurrence of anovulatory cycles following wedge resection is common. When clomiphene citrate successfully corrects the ovulatory defect, but pregnancy does not occur, two alternative methods of treatment have been recommended: combined clomiphene citrate-gonadotropin therapy and bilateral ovarian wedge resection. The former adds the risks of gonadotropin therapy and the latter substitutes potentially hazardous surgical therapy. The pregnancy rate following ovulation induced by these two methods has not been shown to be greater than that following ovulation induced by clomiphene citrate. The limitation of clomiphene citrate to an arbitrary number of apparently ovulatory cycles is not warranted in the absence of other infertility factors. If a patient ovulates, but does not conceive, cyclic clomiphene treatment should be continued. In this way patients may become pregnant with greater safety than after having a laparotomy and removal of functional ovarian tissue. As illustrated by this case report, when clomiphene citrate successfully induces ovulation, treatment should be continued until conception occurs. In this patient, treatment for more than 2 years had no deleterious effects and was followed by a successful pregnancy. REFERENCES
J. W.: In Behrman, S. J., and Kistner, R. W., editors: Progress in Infertility, Boston, 1968, Little, Brown & Company, p. 371. 2. Rust, L. A., Israel, R., and Mishell, D. R., Jr.: An individualized graduated therapeutic regimen for clomiphene citrate, AM. J. 0BSTET. GYNECOL. 1!0: 785, 1974.
January !5, 1976 Am . .J. Ohstel. Gynecol.
repair of uterine prolapse. Although the operation has been modified in several ways, the technique includes the denuding of rectangular areas of similar size on the anterior and posterior walls of the vagina and suturing these mucosal edges together and opposing the denuded surfaces so that drainage canals are created laterally, permitting the egress of uterine or cervical secretions. This procedure is usually restricted to those patients who are postmenopausal, are no longer interested in sexual activity, or have medical complications for which a rapid, noninvasive procedure is desirous. The major disadvantages of this procedure are that ( 1) intercourse is limited and (2) the facility for evaluation of postmenupausal bleeding is compromised. Postmenopausal bleeding subsequent to this procedure poses difficulty in diagnosis and often predisposes the gynecologist to suboptimal procedures, as well as hazardous delay. Dilatation and fractional curettage of the uterus may be precluded by vaginal obliteration and an abdominal hysterectomy may be required for diagnosis and treatment. In those cases with endometrial carcinoma, proper staging ·and review of histologic material was not carried out prior to surgery, compromising the patient's prognosis. In those cases where "breakdown" of the colpocleisis was successful and adequate diagnostic procedures were performed, the patient may be exposed to the risks of bladder and rectal injury. At New York Medical College~Metropolitan Medical Center, we recently encountered one patient who presented with complaint of postmenopausal bleeding 3 years following a Le Fort procedure.
l. Goldzieher,
Ovarian malignancy subsequent to a Le Fort operation NOROHITO SUDO, M.D. THEODORE GOLDBERG, M.D. SANFORD SALL, M.D. Gy'fUicologic Malignancy Service of the Department of Obstetrics and Gynecology, New York Medical College, New York, New York
THE LE FoRT colpocleisis is well known to gynecologists as a reliable procedure for the surgical Reprint requests: Sanford Sail, M.D., New York Medical College, Department of Obstetrics and Gynecology, 1249 Fifth Ave., New York, New York 10029.
J. G., a 56-year-old woman, gravida 3, para 3-0-0-3, whose last menstrual period was in 1965, was admitted on September 22, 1974, for evaluation of postmenopausal bleeding. Her past surgical history included a Le Fort colpocleisis in 1971 for uterine prolapse and cystorectocele. She had been well until June, 1974, when she noted small amounts of intermittent vaginal bleeding. She was seen in the gynecology clinic on July 26, 1974. Pelvic examination revealed no abnormalities other than an obliterated vagina; the Pap smear was Class II, showing mild atrophic atypia. The patient was admitted for a fractional dilatation and curettage. The cervix was approached by gradual dilatation of the right lateral drainage canal with lubricated Hegar dilators, as well as scalpel dissection of resistant fibrous bands. The previous surgery was not disrupted. The cervix was grasped, traction was applied, and fractional dilatation and curettage and cervical punch biopsies were performed. The pathology report revealed small amounts of moderately differentiated adenocarcinoma. Evaluation of metastatic sites of disease was negative. Our impression at that time was Stage Ia, Grade 2, endometrial carcinoma. Laparotomy revealed a 5 by 5 em. left adnexal mass with papillary seeding on the Fallopian tubes, the uterus, and the right ovary. There was diffuse seeding of tumor over the serosal surfaces of the small intestine and omentum. The liver, spleen, and kidneys were normal. A total abdominal hysterectomy and bilateral salpingo-oophorectomy and omentectomy were performed. Extirpation of the cervix was not hindered by the prior Le Fort procedure. The bulk of the tumor was removed, leaving diffuse small metastatic
Communications in brief 211
Volume 124 Number 2
Table I. Pelvic malignancy subsequent to aLe Fort procedure Authors, year, and no. of cases of malignancy in sems of LeFort operations
Mazer and Israel' (1948) l/43 Falk and Kaufman 1 (1955) l/100 Hanson and Keete!3 (1969) 1/288 Hanson and Keetel 3 ( 1969) Sudo, Goldberg, and Sail (1975)
l/74
Diagnostic method
Histology
Further treatment
TAH-BSO TAH D&C D&C, breakdown not mentioned D&C, no breakdown
Endometrial carcinoma Endometrial carcinoma Endometrial carcinoma Endometrial carcinoma
None None ICR* + T AH-BSO ICR
Ovarian carcinoma
T AH-BSO + external teletherapy
*Intracavitary radium. deposits. Surgical clips were placed in areas of larger metastatic concentrations. The pathology report revealed papillary adenocarcinoma of the left ovary. Postoperative cobalt-60 teletherapy was initiated on October 22, 1974 delivering 3,000 r to the whole abdomen in 4 weeks, given through AP-PA portals, blocking the kidneys posteriorly. This was followed by 2,000 r to the whole pelvis.
Pelvic malignancy following aLe Fort operation has been reported in only four instances, all of which have been endometrial in origin (Table 1). There are no reported cases of carcinoma of the cervix. 3 This is the first reported case of ovarian malignancy following a Le Fort colpocleisis. REFERENCES 1. Mazer, C., and Israel, S. L. : The Le Fort colpocleisis: An analysis of 43 operations, AM. J. OssTET. GYNECOL. 56: 944, 1948. 2. Falk, H . C., and Kaufman, S. Partial colpocleisis: The Le Fort procedure, Obstet. Gynecol. 5: 617, 1955. 3. Hanson, G. E., and Keetel, W. C.: The Neugebauer-Le Fort operation: A review of 288 colpocleises, Obstet. Gynecol. :J4: 352, 1969.
Benign melanosis of the vagina and cervix YOSHIAKI TSUKADA, M . D . Department of Pathology, Roswell Park Me1Mriallnstitulil, Buffalo, New York MELANOTIC lesions of the vagina and cervix, benign or malignant, are rare. The majority of such lesions should be regarded as malignant until proved otherwise, 1 but there are occasional benign cases. This report . illustrates a case of benign melanosis of the vagina and cervix in a 46-year-old woman which remained unchanged in a 13 year follow-up .
This 46-year-old black woman, gravida 4, para 2, abortus 2, was referred to this institute 13 years ago because of discoloration of the vaginal mucosa. She had had irregular Reprint requests: Yoshiaki Tsukada, M.D., Department of Pathology, Roswell Park Memorial Institute, Buffalo, New York 14203.
Fig. 1. Photomicrograph of the vaginal mucosa. (Section stained by Fontana stain for melanin; x220.) and heavy menstruation for the last 6 years and had been under the care of a physician, who noted the discoloration recently. On examination at this institute, irregular patches of bluish discoloration were noted on the vagina and portio vaginalis. The vaginal lesion was on the anterior wall, beginning at the right anterior fornix, and involved the upper two thirds of the vaginal canal, measuring about 3 em. in width. The area was neither raised nor firm and was normal on palpation. The cervical discoloration was noted at the 3 and 9 o'clock positions, each measuring about 0.7 em. Biopsies of the lesions revealed pigmentation of the basal layer of the squamous epithelium with melanin pigment. Melanocytes with dendrites and melanin pigment were evident among pigmented epithelial cells (Fig. 1). She has been followed at the outpatient clinic and the lesions have not changed. Another biopsy, obtained recently, showed the same histologic feature.
Benign melanotic lesions ofthe vagina and/or cervix are rare and only few cases have been documented . Nigogosyan, de la Pava, and Pickren 2 studied the vaginal mucosa of 100 random autopsies and found a similar lesion to that of the present case in three cases. All three patients were elderly white women. In one case the pigmentation was extensive. This patient received radiation to the uterus for postmenopausal bleeding 9 months before death. In the other two the pigmented areas were small. In none of the cases were