274

Communications

in brief

one may expect to see more cases of tuba-ovarian abscesses due to saprophytic organisms. REFERENCES

El-Bagoury. S. M., and Fakhr. M. M.: J. Egypt. Pub. Health Assoc. 46: 114, 1971. 2. Corfman, P. A., and Sheldon. J, S.: AM. J. OBSTET. 1.

GYNECOL.

100: 448,

1968.

Microinvasive squamous-cell carcinoma of the vulva KIANOOSH EDWARD

N.

JAFARI, M.D. CARTNICK,

M.D

Department of Obstetrics and Cynecobg, Mercy Hospital. Rockville Center. New York, and Nassau County Medical Center, East Meadow, Neur York, and the Health Sciences Center, State University of New York at Stony Brook, New York

THERE ARE many articles on the treatment Of’ in SitU and invasive squamous-cell carcinoma of the vulva. Radical vulvectomy and bilateral inguinal lymphadenectomy with or without pelvic nodes dissection is generally accepted treatment for invasive carcinoma of the vulva. Many methods of treatment for in situ squamous-cell carcinoma of the vulva have been used. They range from topical application of 5-fluorouracil or local excision of the lesion to radical vulvectomy, but literature is lacking so far in reports on microinvasive carcinoma of the vulva. Whether this is due to the fact that microinvasive carcinoma of the vulva is a relatively rare finding or it is considered as a frank invasive carcinoma is not clear. Wharton and associates’ reported 25 cases of microinvasive squamous-cell carcinoma of the vulva (invasion of stroma to a depth of 5 mm. or less) treated at the University of Texas M. D. Anderson Hospital between 1944 and 1969. Ten patients in their series had lymphadenectomies. None of the nodes was positive. They believed that the result of their study justified further investigation regarding the treatment of the patients with microinvasive vulvar carcinoma by conservative surgery. We used to consider radical vulvectomy (without node dissection) as an adequate therapy for microinvasive squamous-cell carcinoma of the vulva until we found positive inguinal and pelvic nodes 19 months after vulvectomy in the following case. A SO-year-old, white woman. gravida 4, para 2, was admitted to Mercy Hospital in October, 197 1, with a history of itching of the vulva of 2 years’ duration. She had had a hysterectomy

2 years

prior

to her

present

Reprint requests: Dr. K. Jafari, Department and Gynecology, Cook County St.. Chicago, Illinois 60612.

Hospital,

admission

Nakao and his colleagues’ reported a patient with a well-differentiated microinvasive squamous-cell c’arcinema of the vulva (invasion of stroma to the depth of’ 3 mm.) treated by radical vulvectomy without node dissection in whom contralateral inguinal node metastasis was noted in 7 months and who died 12 months after vulvectomy. Since we have experienced the outcome of therap! in our patient, wc no longer consider vulvectomy 3s an adequate therapy for microinvasive carcinoma of the vulva. At the present time we treat such a lesion as a frank invasive carcinoma. REFERENCES

1. Wharton.

J.

‘I‘.. Gallager, S.. and Rutledge, F. K.: carcinoma of the vulva, AM. J, OBSTET. GYNECOL. 118: 159, 1974. 2. Nakao, C. Y.. Nolan, J. F., DiSaia, P. J., et al.: “Microinvasive” epidermoid carcinoma of the vulva with an unexpected natural history, AM. J. OBSTET. GYNECOL. 120: 1122, 1974. Microinvasive

Rectovaginal endometriosis: An isolated enigma CHARLES ROBERT

M. ISRAEL,

MARCH,

M.D

M.D.

Section of Reproductive B&o@, Dcpartnunt oj Obstetrics Gynecology, Women’s Ho&al, University of Southern California School of Medirine, Los Angeles, California ENDOMETRIOSIS,

been reported

for

of Obstetrics

1825 West Harrison

uterine prolapse. Physical examination revealed thickened white epithelium in several areas of the labia minora and majora. Multiple biopsies were performed and the result> were reported as “in situ squamous-cell carcinoma with earl) invasion.” The patient underwent radical vulvectomy (without node dissection). Pathologic examination of the surgical specimen revealed squamous-cell carcinoma with microinvasion, less than 1 mm. depth. In May, 1973, enlarged inguinal nodes were noted, which were biopsied and reported as due to metastatic squamouscell carcinoma. She underwent inguinal and pelvic node dissection. Because of positive obturator and iliac nodes. external radiation to the pelvis and inguinal area was started. Five months later, as persistent disease was evident, a course of chemotherapy consisting of Bleomycin. Cytoxan. and Oncovin was administered. In October, 1973, she returned to the hospital with hemorrhage from the femoral artery which was due to the tumor invasion. Ligation of the femoral artery and suhsequently amputation of the right leg was performed. She died within a month from pelvic recurrence.

sor, rics ern Los

and

a disease of uncertain origin, has with increasing frequency over the past

Reprint requests: Dr. Charles M. March, Assistant ProfesShction ol Reproductive Biology, Department of Obstetand Gynecology, Women’s Hospital/University of SouthCalifornia School of Medicine, 1240 North Mission Road, Angeles, California 90033.

Volume Number

125 2

Table

I. Case reports:

Communications

preoperative

Parity Complaints Pelvic examination Pertinent

275

information Patient

Age

in brief

A. B.

Patient

C. H.

30 o-o-o-o Dysmenorrhea, dyspareunia, dyschezia, rectal bleeding Cul-de-sac mass (3 cm.)

20 o-o-o-o Dysmenorrhea, dyspareunia, dyschezia Cul-de-sac mass (5 cm.)

Extraluminal Normal

Extraluminal mass (at 7 cm.) Right hydroureter and hydronehprosis

stuflies:

Sigmoidoscopy IVP

mass (at 10 cm.)

20 years. Its appearance in younger patients, the occasional association with malignancy, and the continuous profusion of metastatic sites all attest to the ubiquitous nature of endometriosis. Recently, two patients in the Endocrine-Infertility Clinic of the Women’s Hospital, Los Angeles County/University of Southern California Medical Center, were found to have similar cul-de-sac masses (Table I). At the time of exploratory laparotomy, both masses proved to be isolated endometriosis of the rectovaginal (R-V) septum. The only previous report of endometriosis limited to the R-V septum was published by Pfannenstiel in 1897. After mechanical bowel preparation, both patients underwent exploratory laparotomy. The similarity in operative findings was most striking: extensive endometriotic involvement of the upper rectovaginal septum by a totally retroperitoneal mass with no endometriosis elsewhere in the peritoneal cavity. In each case, the right ureter was densely adherent to the endometriotic mass and required careful isolation and release. Each mass was resected at the junction of the right utero-sacral ligament and the posterior cervix. A presacral neurectomy and modified Gilliam uterine suspension completed the surgery. The histopathology of both operative specimens was quite similar. Well-preserved endometrial glands and abundant stroma were interspersed between areas of old hemorrhage and fibrous tissue. Leukocyte infiltration was minimal. Superior to the mass, the resected nerves Here surrounded by loose areolar tissue. However, as the nerves coursed inferiorly, they became intimately associated with the endometriotic growths. Progestational effect was marked throughout the endometrial stroma. Postoperatively, both patients were treated with suppressive depomedroxyprogesterone acetate therapy for 6 months. Eighteen months after surgery both patients are symptomfree. Sampson’s theory of endometrial transportation and implantation partially explains uterosacral ligament and R-V septum involvement. However, the “extrapleuralization” concept must be included to fully explain the surgical findings in our two patients. Harbitz’ demonstrated that free intrapleural trans-

(mild)

plants of endometrium could pass through and be completely covered by the parietal pleura. In our cases, the parietal peritoneum could have acted in a similar fashion. Any patient presenting with complaints or findings suggestive of endometriosis, irrespective of the presence or absence of palpable disease, should undergo a complete evaluation, including laparoscopy and biopsy if indicated. Impression alone does not warrant the institution of suppressive steroidal therapy. If a mass is present in the R-V septum, evaluation should include intravenous pyelogram (IVP), barium enema, and sigmoidoscopy. With endometriosis of the R-V septum, laparotomy is mandatory. Although preoperative suppressive steroidal therapy may soften the involved areas and help to define tissue planes, it will not resolve bowel or R-V septum endometriosis. Occasionally, at surgery, bowel resection, with or without colostomy, will be necessary. Therefore, a thorough preoperative mechanical bowel preparation should be carried out. The ureter(s) must be identified during laparotomy, and, if involved in the endometriotic mass, must be released or reconstructive ureteral surgery performed. Following resection, pathologic confirmation of the diagnosis must be obtained to exclude malignancy.’ Although rare in cases of both ovarian and extraovarian endometriosis, malignancy may be found more commonly as the incidence of endometriosis rises and as greater emphasis is placed upon histologic confirmation. Since even apparent total resection will leave microscopic foci, suppressive hormonal therapy should be continued postoperatively for 6 to 12 months following conservative surgery for isolated rectovaginal endometriosis.

REFERENCES

1. Harbitz, H. F.: Clinical, pathogenetic and experimental investigations of endometriosis, Acta Chir. Stand. 74 (Suppl. 30): 1, 1934. 2. Dockerty, M. B., Pratt, 1. H., and Decker, D. G.: Primary adenoca;cinoma of th; rectovaginal septum probably arising from endometriosis. Report of 2 cases, Cancer ‘7: 893,

1954.

Rectovaginal endometriosis: an isolated enigma.

274 Communications in brief one may expect to see more cases of tuba-ovarian abscesses due to saprophytic organisms. REFERENCES El-Bagoury. S. M.,...
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