New Treatment of Ovarian Cysts
CS was first described as the triad of ARM, hemisa-crum and presacral mass 23 . The radiological aspect of the sacrum described by Currarino is the so-called sickle-shaped sacrum , which is caused by the presence of a hemisacrum with preservation of the first sacral vertebra. This finding is pathognomonic for the diagnosis CS 103 . According to Cama 16 , classification of sacral anomalies presents (1) total sacral agenesis with normal or short transverse pelvic diameter, and the defect extending to include some lumbar vertebrae, (2) total sacral agenesis with intact lumbar vertebrae, (3) partial agenesis or hypodevel-oped sacrum (preserved S1), (4) hemisacrum and (5) coccygeal agenesis. Following this classification, CS has been characterised as a type 4 sacral anomaly. Different forms of ARM can be present in CS, such as rectourethral fistula, rectovestibular fistula and rectocloacal fistula 73 . It is estimated that 29 of ARM are associated with sacral anomalies 97 . The most...
A particular form of malignant disease affecting pregnancy is that arising from the placenta itself (gestational trophoblastic neoplasia), comprising hydatiform mole, invasive mole, choriocarcinoma and placental site trophopbastic tumour. It is more common at the extremes of reproductive age, in the Far East and Asia and if previous pregnancies have been affected. The pregnancy itself is non-viable and concerns about the fetus do not apply. These tumours generally respond well to chemotherapy, even if metastatic spread has occurred, with a mortality of
In trophoblastic neoplastic disease, uterine evacuation may be adequate surgical management but hysterectomy may be required in more invasive disease, especially in older women. Surgery may also be required for torsion of, or haemorrhage into, ovarian cysts. Chemotherapy maybe required if human chorionic gonadotro-phin levels remain elevated or in metastatic disease. In terms of anaesthetic management, the above considerations should be taken into account and appropriate measures taken regarding investigation (including liver and thyroid function blood tests and chest radiography), monitoring and management. General anaesthesia is usually recommended since uterine bleeding may be rapid and severe, and blood should be cross-matched and ready before surgery.
Some authors advocate percutaneous aspiration with fluid analysis for viscosity, CA-125, carcinoembryonic antigen (CEA) and cytology. CA-125 and CEA levels have been found to be elevated in neoplastic cysts, and lower in pseudocysts (22). Cytologic analysis has an accuracy of approx 88 for mucinous cysts and its diagnostic value in serous cystadenomas appears to be limited (23).
After mobilization of the liver, countertraction is maintained by the nondominant hand of the surgeon (B). The interface between the cyst and the hepatic parenchyma is identified and developed the wall of the cyst is usually thick and rarely ruptures. With deeper dissection, compressed vessels and bile ducts become evident and should be preserved. The dissection is completed circumferentially and the cystadenoma is enucleated and sent for histologic analysis to exclude occult cystadenocarcinoma.
Hepatic cysts are classified according to the presence or absence of a parasitic etiology. They seldom lead to hepatic dysfunction and are mostly asymptomatic. The treatment is always individualized according to the origin and presence of symptoms. The choice between unroofing versus resection is dictated by site, number of cysts, malignant potential (cystadenoma cystadenocarcinoma), and parasitic infection (see next chapter). Malignant potential is rare and is not a primary concern.
Dermoid cysts occur when surface ectodermal elements are sequestered along the closure lines of the fetal bony sutures. These cystic dermoids demonstrate the superotemporal and the superonasal locations. Figure 2.43. Dermoid cysts occur when surface ectodermal elements are sequestered along the closure lines of the fetal bony sutures. These cystic dermoids demonstrate the superotemporal and the superonasal locations.
Management of trophoblastic disease in the first instance involves evacuation of the uterus. This should always be done using a suction curette. In the presence of persistently elevated human chorionic gonadotrophin (hCG) levels or continuing problems with haemorrhage, further evacuation may be necessary. This should normally be discussed with a gestational trophoblastic disease centre because of the risk of perforation, haemorrhage or infection. Thereafter, if the hCG levels remain elevated, chemotherapy should be instituted. The vast majority of patients will respond to these measures. For the small minority whose hCG levels remain elevated following chemotherapy, more definitive surgical management may be required, in the form of total abdominal hysterectomy. Elevated hCG levels predispose to ovarian cyst formation but this should not encourage bilateral oophorectomy at the time of hysterectomy unless there is another pre-existing reason. Total abdominal hysterectomy in the...
Clomiphene is an oral synthetic triphenylethylene derivative with estrogen agonist antagonist characteristics (19). The clinically available preparations contain an approximate 3 2 mixture of two stereoisomers, enclomiphene and zuclomiphene, which show distinctly different patterns of agonistic and antagonistic activity in vitro (20). Clomiphene is metabolized in the liver, and its biological half-life is reported to be 5 days (21). The drug is contraindicated in patients with liver disease, endometrial carcinoma, undiagnosed abnormal uterine bleeding, ovarian cysts not rrelated to PCOS, and during pregnancy.
In 1986, a pilot study was started in the United Kingdom to test the feasibility and tox-icity associated with long-term tamoxifen treatment in women at high risk of breast cancer.93 Between October 1986 and June 1993, a total of 2,012 women were accrued and randomly assigned to tamoxifen (20 mg day) or placebo for up to 8 years. A total of 265 women were on HRT at entry and 131 were randomized to tamoxifen treatment. With a median follow-up of 36 months and with a compliance of 77 percent of the women assigned to the treatment arm, no obvious effect on bone mineral density was observed and only marginal effects on clotting factors. Tamoxifen was associated with a significant reduction in the serum cholesterol level. More importantly, there was an increased incidence of uterine fibromata and benign ovarian cysts however, no increase in endometrial cancer incidence was reported.
In 1959, Letton and Wilson reported the first non-resective treatment of traumatic rupture of the neck of the pancreas. The right stump of the pancreatic head was oversewn, and a Roux-en-Y loop of jejunum was anastomosed to the left body tail of the pancreas. In 1984, Dagradi and Serio reported the first central pancreatectomy for an insulinoma, and in 1988, Fagniez, Kracht, and Rotman reported two central pancreatectomies performed for an insulinoma and a serous cystadenoma. At least 150 central pancreatectomies have been reported so far without mortality. Central pancreatectomy involves anatomic removal of benign or borderline lesions of the neck and or proximal body of the pancreas together with 1 cm of normal tissue on both sides. The goal is to preserve at least 5 cm of the normal pancreatic tissue of the body tail of the pancreas that would otherwise be removed with a complete left pancreatectomy.
Surgical approach of the orbit and, in particular when concerning the two anterior thirds 4 can be adequately addressed by the classic ophthalmologic approaches, whatever variety or variant they may be. On the contrary, neurosurgical approaches that allow access to the posterior third of the orbit are more aggressive and can, on occasions represent a risk for the frontal lobe during retraction operations. Furthermore, the lateral approach as described by Kronlein is of particular interest since it associates the benefits of a trans browsal and those of an orbitotomy of the roof and the external margin of the orbit. It spares the frontal lobe since it does not necessitate cerebral retraction. This approach is useful for excision of accessible tumours from a frontal view by the superolateral and inferolat-eral quadrants, independently of their intra-conical or extra-conical location. As this approach permits access to the superior orbital fissure it concerns tumours situated, from a...
Aetiologies pertaining to orbital tumours are great in number, and often necessitate entirely different procedures. In order to avoid proposing surgery that may be, on occasions, useless (for example, rhabdomyosarcoma in children), or, inversely, to avoid deferring surgery that is imperative (in the event of orbital meningioma), it is necessary to detail the clinical and para-clinical characteristics of the principal aetiologies which relate to tumours. Adult and paediatric varieties of OTs constitute two clusters of distinctive histological entities (Table 1). Diagnosis of an orbital mass is based on clinical and evolutive elements as well as information obtained from modern imaging. Clinical examination has to be conducted with care measurement, direction of proptosis, impairment of ocular motility, com-pressive optic neuropathy, age at the onset and unilateral or bilateral prop-tosis are important features. Benign tumours like dermoid cysts or haeman-giomas grow slowly whereas...
Exocrine pancreatic tissue, which is located within or adjacent to the liver in some fish, is also affected by DEN metabolites. Exposure of larval or juvenile mangrove rivulus for 1 week or continuously to DEN produced pancreatic adenomas composed of duct-like arrangements of cuboidal or flattened exocrine pancreatic cells (Thiyagarajah and Grizzle, 1986). Mangrove rivulus that were first exposed while larvae, but not those first exposed as juveniles, developed cystadenomas and adenocarcinomas after continuous exposure to DEN for 20 weeks. Cystadenomas consisted of cystic pancreatic ducts that were occasionally folded and were surrounded by moderate amounts of periductal collagen. Adenocarcinomas were characterized by extensive duct-like structures infiltrating mesenteries and adipose tissue. Rainbow trout exposed to DEN had metaplastic pancreatic acinar cells in the liver (Lee et al., 1989a). These pancreatic cells apparently developed from hepatocytes, and this change was most...
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