Analytic bias of thyroid function tests: analysis of a College of American Pathologists fresh frozen serum pool by 3900 clinical laboratories

CONTEXT

In proficiency testing surveys, there are differences in the values reported by users of various analytic methods. Two contributors to this variation are calibrator bias and matrix effects of proficiency testing materials.

OBJECTIVES

(1) To quantify the biases of the analytic methods used to measure thyroid-stimulating hormone, thyroxine, triiodothyronine, free thyroxine, and free triiodothyronine levels; (2) to determine if these biases are within allowable limits; and (3) to ascertain if proficiency testing materials correctly identify these biases.

DESIGN

A fresh frozen serum specimen was mailed as part of the 2003 College of American Pathologists Ligand and Chemistry surveys. The means and SDs for each analytic method were determined for this sample as well as for a proficiency testing sample from both surveys. In the fresh frozen serum sample, target values for thyroxine and triiodothyronine were determined by isotope dilution/liquid chromatography/tandem mass spectrometry. All other target values in the study were the median of the means obtained for the various analytic methods.

MAIN OUTCOME MEASURES

Calibration biases were calculated by comparing the mean of each analytic method with the appropriate target values. These biases were evaluated against limits based on intra- and interindividual biological variation. Matrix effects of proficiency testing materials were assessed by comparing the rank of highest to lowest analytic method means (Spearman rank test) for each analyte.

PARTICIPANTS

Approximately 3900 clinical laboratories were enrolled in the College of American Pathologists Chemistry and Ligand surveys.

RESULTS

The number of methods in the Ligand Survey that failed to meet the goals for bias was 7 of 17 for thyroid-stimulating hormone and 11 of 13 for free thyroxine. The failure rates were 12 of 16 methods for thyroxine, 8 of 11 for triiodothyronine, and 9 of 11 for free triiodothyronine. The means of the analytic method for the proficiency testing material correlated significantly (P < .05) only with the fresh frozen serum means for thyroxine and thyroid-stimulating hormone in the Chemistry Survey and free triiodothyronine in the Ligand Survey.

CONCLUSIONS

A majority of the methods used in thyroid function testing have biases that limit their clinical utility. Traditional proficiency testing materials do not adequately reflect these biases.

Vulvar cancer in human immunodeficiency virus-seropositive premenopausal women: a case series and review of the literature

This review describes three cases of human immunodeficiency virus-infected women who were diagnosed with vulvar cancer before age 40 years. A retrospective chart review was performed for three patients who were younger than 40 years of age and who had histologically confirmed invasive squamous cell carcinoma of the vulva diagnosed between 1999 and 2002. Demographic, clinical, and laboratory data were recorded. Three human immunodeficiency virus-seropositive women were diagnosed with invasive squamous cell carcinoma of the vulva, stages IA, IB1, and III. All cases were characterized by extensive surrounding vulvar, vaginal, and cervical intraepithelial neoplasia. CD4 cell counts were 250, 330, and 900 cells/uL. Two patients experienced previous acquired immune deficiency syndrome-defining illnesses: toxoplasmosis and cervical cancer. Vulvar cancer in young human immunodeficiency virus-seropositive women may be associated with other human papillomavirus-related diseases and immunosuppression, as evidenced by low CD4 counts and the presence of antecedent acquired immune deficiency syndrome-defining illnesses.

Novel techniques to improve split-thickness skin graft viability during vulvo-vaginal reconstruction

BACKGROUND

Split-thickness skin grafts are often utilized for vulvo-vaginal reconstruction. Unfortunately, infection and sloughing may occur in up to 22% of patients with standard techniques especially at irradiated recipient sites.

CASES

We report seven cases of vulvo-vaginal reconstruction using split-thickness skin grafts. In this series, we used fibrin tissue adhesives with and without vacuum-assisted closure devices to augment graft adherence and viability. We briefly describe the clinical history, surgical techniques, and outcomes of the cohort.

CONCLUSION

Fibrin tissue adhesives and wound vacuum-assisted closure devices may improve the viability of split-thickness skin grafts during vulvo-vaginal reconstruction.

The Use of Acellular Dermal Graft for Vulvovaginal Reconstruction in a Patient With Lichen Planus

BACKGROUND

Vulvovaginal lichen planus is an inflammatory dermatosis that can progress to an erosive form with scarring of the vulva, resorption of the labia minora, vaginal synechiae, and vaginal obliteration secondary to desquamative vaginitis. Traditionally, conservative medical therapy has consisted of topical corticosteroids and immunosuppressants.

CASE

A 61-year-old woman with a history of refractory erosive vulvovaginal lichen planus presented with complete obliteration of the vaginal vault. The patient failed both medical and conservative surgical management and desired definitive management. After performing a skinning vulvectomy and simple vaginectomy, acellular dermal graft was used for grafting the vulva and creating a neovagina.

CONCLUSION

Acellular dermal graft is a suitable graft material for vulvar and vaginal reconstruction in select patients, and it avoids the postoperative pain associated with graft harvest sites.

Comparison of Pooled Fresh Frozen Serum to Proficiency Testing Material in College of American Pathologists Surveys: Cortisol and Immunoglobulin E

Context.—The College of American Pathologists (CAP) provides proficiency testing (PT) surveys to laboratories around the world.

Objectives.—To compare diagnostic assay methods for serum/plasma cortisol and immunoglobulin (Ig) E in terms of their bias and precision, to determine how well CAP PT specimens simulate human serum, and to reassess proficiency test grading criteria in light of these findings.

Design.—A participant-blinded, prospective trial. One vial of pooled fresh frozen serum (FFS) and 4 different admixtures of PT material (PTM) were sent to laboratories participating in PT surveys.

Participants.—Laboratories providing cortisol (&gt;1000) or IgE (&gt;230) results among the subscribers to the CAP surveys, Ligand (General) 2003, set K/KN-A and Chemistry 2003, set C-C.

Main Outcome Measures.—The main outcome measures were (1) bias among laboratories using the same method (peer groups), defined relative to the median of method means (MedMM); (2) imprecision as measured by the SD and coefficient of variation (CV) about each method mean; and (3) total error across laboratories for the FFS cortisol results, defined as |Bias Relative to Reference Method| + 2 SD.

Results.—Cortisol method biases, relative to MedMM, ranged from −22% to 9% for the FFS challenge and from −24% to 36% for comparable PTM challenges. The method biases, relative to the reference method, ranged from −3% to 19% for the FFS challenge. The cortisol method CVs ranged from 4.2% to 13.6% for the FFS challenge and from 4.7% to 12.7% for comparable PTM challenges. Total error across laboratories ranged from 1.4 to 6.9 μg/dL (39 to 190 nmol/L) for the FFS challenge. Immunoglobulin E method biases, relative to MedMM, ranged from −8% to 9% for the FFS challenge and from −7% to 5% for comparable PTM challenges. The IgE method CVs ranged from 3.6% to 6.7% for the FFS challenge and from 3.4% to 9.8% for comparable PTM challenges.

Conclusions.—The bias for cortisol results was less with FFS than with PTM, but imprecision was comparable. The FFS MedMM was 8.5% higher than the reference value. Fresh frozen serum and PTM bias and imprecision for IgE methods were each less than 10%. Because some of the methods demonstrated greater bias when analyzing PTM than FFS, peer group grading of both these analytes is appropriate.

The utility of hand-assisted laparoscopy in ovarian cancer

INTRODUCTION

The traditional approach to patients with ovarian cancer is cytoreductive surgery and surgical staging through a vertical midline laparotomy. While laparoscopy has become an integral part of gynecologic surgery, debulking procedures have not been feasible to date with standard minimally invasive techniques.

METHODS AND MATERIALS

Twenty-five patients with ovarian carcinoma underwent surgical staging and cytoreduction using hand-assisted laparoscopy. We review the surgical technique and clinical outcomes.

RESULTS

Twenty-five patients were managed during this study time frame with hand-assisted laparoscopy. Six patients had apparent advanced stage ovarian cancer at the time of referral, and 17 patients had apparent early-stage ovarian cancer. Of the 19 patients with presumed early-stage disease, 5 patients were upstaged based on retroperitoneal lymph node involvement, 3 with disease to other pelvic structures, and 2 patients had microscopic disease in the omentum. Twenty-two patients had their surgeries completed via hand-assisted laparoscopy, and three cases required conversion to laparotomy for completion of debulking surgery. Complication rates were low with three complications requiring reoperation or hospitalization. The mean hospital stay was 1.8 days for the 22 patients who had a successful hand-assisted laparoscopic evaluation. Operating times were variable and ranged from 81 to 365 min.

CONCLUSION

Hand-assisted laparoscopy may be employed in the initial management of early and advanced stage ovarian carcinoma. This approach allows for thorough evaluation of peritoneal and retroperitoneal structures and surgical cytoreduction while retaining the advantages of minimally invasive surgery.

Expression of beta-cell autoimmunity does not differ between potential dizygotic twins and siblings of patients with type 1 diabetes

Twin studies help to elucidate the contribution of genes and environment to type 1 diabetes (T1DM). The Diabetes Prevention Trial-1 (DPT-1) tested for anti-islet autoantibodies: 34,765 non-diabetic non-twin siblings of patients with T1DM, and 896 non-diabetic potential twins of patients with T1DM. Zygosity (being monozygotic [MZ] or dizygotic [DZ]) was unknown except for 357 non-diabetic subjects with opposite gender to their diabetic twin, who must be DZ. Expression of cytoplasmic islet cell (ICA), GAD65, ICA512 and insulin autoantibodies in 357 different-sex (DZ) potential non-diabetic twins of T1DM patients was, respectively, 4.5%, 4.7%, 3.0% and 2.4%, which was lower than in 539 same-sex potential non-diabetic twins (including MZ and DZ) of T1DM patients for ICA (7.8%, p < 0.05), GAD65 (13.4%, p < 0.0001) and ICA512 (6.5%, p < 0.03). In contrast, expression of ICA, GAD65, ICA512 and insulin autoantibodies was not significantly different in different-sex (DZ) potential twins versus all siblings (respectively, 4.2%, 4.8%, 2.2%, 2.5%), different-sex siblings (3.9%, 4.9%, 2.2%, 2.5%) or same-sex siblings (4.4%, 4.7%, 2.2%, 2.5%) of T1DM patients. In conclusion, anti-islet autoimmunity is not increased in non-diabetic DZ twins of T1DM patients compared to non-diabetic siblings of T1DM patients, suggesting that the greater environmental sharing by twins does not increase risk of anti-islet autoimmunity.

The chemical pathology of insulin resistance and the metabolic syndrome

In this review, we have examined the phenomenon of insulin resistance, a central manifestation of the metabolic syndrome. While it is by no means clear-cut, many new and exciting hypotheses have been proposed to explain this puzzling and enigmatic phenomenon. These studies have also led to a new way of looking at adipose tissue--it is no longer a passive repository of fat. It now actually appears to be a very active endocrine organ. A disturbance in this endocrine function helps contribute to the metabolic syndrome.

Association of hemoglobin level with survival in cervical carcinoma patients treated with concurrent cisplatin and radiotherapy: a Gynecologic Oncology Group Study

OBJECTIVES

To determine if there is an association of hemoglobin level before or during concurrent cisplatin and radiotherapy (RT) with disease outcome in women with locally advanced cervical cancer, and to assess if the association is particularly significant at a specific interval or time during treatment.

METHODS

A retrospective review of 494 patients treated on two consecutive prospective Gynecologic Oncology Group (GOG) trials was conducted. Demographic data, pathologic information, treatment-related factors, and hemoglobin values at baseline and during each week of therapy were collected. Cox proportional hazards model was performed to evaluate the impact of hemoglobin level on progression-free survival (PFS).

RESULTS

Of the combined patients, 278 (56%) and 216 (44%) were diagnosed with Stage II and Stage III/IV disease, respectively. Controlling for age, race, performance status, disease stage, tumor size, cell type, and duration of radiotherapy, mean hemoglobin values during treatment were predictive of disease progression (P < 0.0001). The pretreatment level was not significant when hemoglobin levels during treatment were included in the multivariate analysis. When the 6-week treatment course was divided into 2-week periods (early, middle, and late), analysis revealed hemoglobin values during the late period were the most predictive of disease progression (P = 0.0289).

CONCLUSIONS

Hemoglobin levels during combined radiotherapy and cisplatin were independent predictors of treatment outcome in advanced cervical carcinoma. The pretreatment level was not a significant predictor of outcome when hemoglobin levels during treatment were included in the multivariate regression model. Levels in the last part of treatment were the most predictive of disease recurrence and survival.

The role and assessment of ventricular peptides in heart failure

Although heart failure may be diagnosed readily in its advanced stages, it may be difficult to diagnose clinically in its early stages.Thus, there is a critical need for an inexpensive, simple, rapid,and objective test for heart failure. This article discusses the role and assessment of ventricular natriuretic peptides and related pep-tides in heart failure.

Laparoscopic Exposure in Obese High-Risk Patients With Mechanical Displacement of the Abdominal Wall

BACKGROUND

Patients with morbid obesity or pulmonary disease are at a higher risk for complications during advanced laparoscopic procedures. Higher intraperitoneal carbon dioxide pressures required to elevate the pannus can negatively impact hemodynamic and respiratory parameters.

CASES

We describe a technique that uses a combination of a mechanical retractor and a Foley catheter inserted midway between the umbilicus and the pubic symphysis that assists in elevating the anterior abdominal wall. In 3 cases this technique allowed for a low-pressure pneumoperitoneum during advanced laparoscopic pelvic surgery, which resulted in improved hemodynamic parameters and pulmonary function in these high-risk patients.

CONCLUSION

The Foley Lap-Lift facilitated laparoscopy through mechanical abdominal wall elevation and allowed for a lower-pressure pneumoperitoneum. This technique is an addition to traditional operative laparoscopy in select high-risk patients.

Clinicopathological analysis of c-kit expression in carcinosarcomas and leiomyosarcomas of the uterine corpus

OBJECTIVE

The purpose of this study was to evaluate the expression of the protooncogene, c-kit, in carcinosarcomas and leiomyosarcomas of the uterine corpus and determine the associations between c-kit expression and clinicopathologic factors, including clinical outcome.

METHODS AND MATERIALS

Using a polyclonal anti-KIT-antibody, immunohistochemical staining was performed on formalin-fixed paraffin-embedded tissue blocks from 21 carcinosarcomas, 17 leiomyosarcomas, and 1 endometrial stromal sarcoma. KIT-positive tumors were defined as those tumors demonstrating immunopositivity in > or =30% of tumor cells examined. KIT-negative lesions demonstrated immunopositivity in <30% of tumor cells. Two authors independently scored the slides as positive or negative. Staining was repeated on all specimens and independently scored, and in the occasion of a mismatch, a third staining was performed. The carcinosarcomas were catalogued as to whether the sarcomatous and/or carcinomatous elements expressed c-kit. Clinical data were abstracted for those patients with uterine carcinosarcomas. The associations between clinicopathologic characteristics and c-kit expression were compared using univariate and multivariate analyses. Kaplan-Meier curves based on c-kit expression were plotted for progression-free and overall survival and compared using the log-rank test.

RESULTS

Nine of 21 (43%) carcinosarcomas demonstrated immunopositivity for the KIT receptor, although staining was relatively weak. In contrast, only 1/17 (6%) leiomyosarcomas demonstrated KIT immunopositivity (P = 0.029). The solitary endometrial stromal sarcoma evaluated did not demonstrate significant KIT positivity. The majority of KIT-positive carcinosarcomas (6/9 (67%)) demonstrated KIT presence in the sarcomatous portion as compared to the carcinomatous portion (4/9 (44%)). No clinical factor had a statistically significant association with c-kit expression. The lack of c-kit expression was the only factor that was significantly associated with disease recurrence in univariate and multivariate analyses (P < 0.05), although there appeared to be a trend toward a low stage associated with kit positivity. The median progression-free interval for the KIT-negative cohort was 8 months, while it had not been reached for the KIT-positive cohort after median follow-up of 15 months (P = 0.0462).

CONCLUSIONS

A significant proportion of carcinosarcomas of the uterine corpus display immunoreactivity for c-kit. Patients with KIT-positive carcinosarcomas may have an improved progression-free survival compared to KIT-negative tumors; however, further data are needed to determine whether this finding is confounded by stage.

The utility of gastrojejunostomy in secondary cytoreduction and palliation of proximal intestinal obstruction in recurrent ovarian cancer

BACKGROUND

Gastrointestinal obstruction is a common complication of recurrent ovarian cancer. Proximal intestinal obstruction, at the level of the duodenum or proximal jejunum, can result from bulky intraperitoneal or retroperitoneal disease. Classic management has been palliation of symptoms with a gastrostomy or jejunostomy tube.

CASE

We describe a series of four patients with recurrent ovarian carcinoma and proximal intestinal obstructions treated with a bypass stapled side-to-side gastrojejunostomy at the time of secondary cytoreduction or surgical palliation. The clinical history, preoperative evaluation, surgical technique, and outcomes of each patient are reviewed.

CONCLUSIONS

Gastrojejunostomy may offer patients with ovarian cancer and a proximal intestinal obstruction symptomatic relief and an opportunity for resumption of enteral feedings.

Prevention strategies for type 1 diabetes mellitus: current status and future directions

Type 1 diabetes mellitus affects about 1 in 300 people in North America and Europe. Epidemiological studies indicate that the incidence and thus prevalence of type 1 diabetes is rising worldwide. Intervention in autoimmune type 1a diabetes could occur at the time of diagnosis or, preferably, prior to clinical presentation during the 'prediabetic' period (e.g. prevention). Prediabetes is best recognised by the detection of islet autoantibodies in the serum. Promising intervention strategies include monoclonal antibody therapies (e.g. anti-CD3, anti-CD25, anti-CD52 or anti-CD20 monoclonal antibodies), immunosuppression (e.g. calcineurin inhibitors, B7 blockade, glucocorticoids, sirolimus (rapamycin), azathioprine or mycophenolate mofetil), immunomodulatory therapies (e.g. plasmapheresis, intravenous immunoglobulin, cytokine administration, adoptive cellular gene therapy) and tolerisation interventions (e.g. autoantigen administration or avoidance, altered peptide ligand or peptide-based therapies). To date, islet and pancreas transplantation have essentially been reserved for patients with long-standing diabetes who have complications and are also in need of a concurrent kidney transplant. None of the therapies attempted to date has produced long-term remissions in new-onset type 1 diabetes patients and no therapies have been shown to prevent the disease. Nevertheless, with advances in our understanding of basic immunology and the cellular and molecular mechanisms of tolerance induction and maintenance, successful intervention therapies will be developed. The balance between safety and efficacy is critical. Higher rates of adverse events might be more tolerable in new-onset type 1 diabetes patients if the therapy is extremely effective at inducing a permanent remission. However, therapies must not harm the beta-cells themselves or any organ system that is a potential target of diabetes complications, such as the nervous system, retina, cardiovascular system or kidney. In the treatment of prediabetes, successful therapies should provide a level of safety similar to that of currently used vaccines and a high level of efficacy.

Screening strategies for the identification of multiple antibody-positive relatives of individuals with type 1 diabetes

The objective of this study was to determine the extent to which different screening strategies could identify a population of nondiabetic relatives of a proband with type 1 diabetes who had two or more immunologic markers from the group consisting of islet cell antibodies (ICA), micro insulin autoantibodies (MIAA), GAD65 autoantibodies (GAA), and ICA512 autoantibodies (ICA512AA). Relatives of subjects with type 1 diabetes were screened for ICA as part of the Diabetes Prevention Trial-Type 1. A total of 71,148 samples were also tested for GAA and ICA512AA. IAA results were available on 17,207 of these samples using a protein A/protein G MIAA assay as well. The study population was defined to be those in which all four antibodies were tested. There were 1010 (5.9%) relatives with a single autoantibody on initial screening and 394 (2.3%) with two or more autoantibodies. GAA was more sensitive than ICA [GAA, 91% (357 of 394); ICA, 82% (324 of 394)] in the detection of multiple antibody-positive individuals. The addition of ICA512AA to GAA as a screening test increased sensitivity to 97% (381 of 394), whereas adding ICA512AA to ICA as a screening test increased sensitivity to 93% (367 of 394). GAA and ICA identified somewhat nonoverlapping subgroups of multiple antibody-positive subjects. Thus, the substitution of GAA or ICA for the other failed to detect 8-17% of multiple antibody subjects. Higher ICA titers were associated with increased percentages of multiple antibody-positive subjects; 86% of subjects having Juvenile Diabetes Foundation titers of at least 160 were positive for two or more antibodies. A screening strategy combining GAA and ICA512AA resulted in a higher sensitivity than using any marker individually, although statistically it was not significantly higher than using GAA alone. Screening for any three antibodies guaranteed that all multiple antibody-positive subjects were detected. Screening for two antibodies at one time and testing for the remaining antibodies among those who are positive for one resulted in a sensitivity of 99% for GAA and ICA, 97% for GAA and MIAA or GAA and ICA512AA, 93% for ICA512AA and ICA, 92% for MIAA and ICA, and 73% for ICA512AA and MIAA. From a laboratory perspective, screenings for GAA, ICA512AA, and MIAA are semiautomated tests with high throughput that, if used as initial screen, would identify at first testing 67% of the 2.3% of multiple antibody-positive relatives (100% if antibody-positive subjects are subsequently tested for ICA) as well as 4.7% of relatives with a single biochemical autoantibody, some of whom may convert to multiple autoantibody positivity on follow-up. Testing for ICA among relatives with one biochemical antibody would identify the remaining 33% of multiple antibody-positive relatives. Further follow-up and analysis of actual progression to diabetes will be essential to define actual diabetes risk in this large cohort.

Surgical staging in patients with ovarian tumors of low malignant potential

OBJECTIVE

To compare the outcomes of patients with ovarian tumors of low malignant potential who had complete surgical staging with those who were unstaged to determine whether the rate of recurrence or survival was affected by surgical staging.

METHODS

A retrospective chart review was performed on 93 consecutive patients who had surgery for histologically confirmed tumors of low malignant potential between 1979 and 1997. Two cohorts of patients were identified: patients who had classic surgical staging (n = 48) versus those who were not staged (n = 45). Outcome data were recorded for patients and compared between the two groups.

RESULTS

Early stage (I or II) disease was diagnosed in 31 of 48 patients who had surgical staging and 42 of 45 patients who were not staged (P =.001). In 17% of patients their stage was upgraded on the basis of surgical staging, as a result of retroperitoneal involvement in only 6% of those cases (three of 48 staged patients). During the study interval, the frozen section diagnosis of low malignant potential tumor of the ovary was changed to a final diagnosis of invasive cancer in eight other patients. There were three recurrences and two deaths in both the staged and unstaged low malignant potential groups. The average duration of follow-up was 6.5 +/- 4.2 years and was similar in the two groups. Overall 5-year survival was approximately 93% for all stages.

CONCLUSION

Survival and recurrence rates were not significantly different between staged and unstaged patients who had surgery for low malignant potential tumors of the ovary.

Successful management of metastatic placental site trophoblastic tumor with multiple pulmonary resections

INTRODUCTION

Placental site trophoblastic tumor (PSTT) is an uncommon variant of gestational trophoblastic disease. Most of these tumors are confined to the uterus and treated with a simple hysterectomy. However, 30% of these patients will present with metastatic disease. These patients are typically treated with a hysterectomy followed by adjuvant multiagent chemotherapy. Unfortunately, PSTT is relatively resistant to chemotherapy when compared to other forms of gestational trophoblastic disease. Consequently, these patients have a poor prognosis.

CASE

We present a case report of a 26-year-old female with multiple metastatic lesions to the lungs unresponsive to chemotherapy who was managed with multiple pulmonary resections. She has remained clinically free of disease at 28 months of follow up.

CONCLUSION

A patient with metastatic PSTT was successfully managed with radical surgical resection of chemotherapy-resistant sites.

Modified technique for urinary diversion with incontinent conduits

BACKGROUND

Incontinent urinary diversions are frequently performed in gynecologic oncology. The incontinent urinary diversions generally utilize a short segment of distal ileum or colon as a conduit. Conduit complications such as anastomosis leaks and strictures may be related to the technique utilized for inserting and securing the ureters and the degree of postimplant manipulation.

TECHNIQUE

We describe a technique using a metal Yankaur suction device placed through the conduit's matured stoma to facilitate the mucosa-to-mucosa anastomosis of the ureters. This procedure allows for tension-free ureteral anastomoses, the isolation of the ideal conduit length, optimal stomal maturation, and reduced manipulation of the conduit after the ureteral anastomoses.

CONCLUSION

This modification provides an elegant, yet simple and expedient, method of ureteral anastomosis to the incontinent urinary conduit.

Autoimmune polyglandular syndrome. II: Clinical syndrome and treatment

A high index of suspicion should be maintained whenever one organ-specific autoimmune disorder is diagnosed in order to prevent morbidity and mortality from the index disease as well as associated diseases. Further definition of susceptibility genes and autoantigens, and understanding of immune tolerance and the induction and propagation of autoimmune reactions should prove to be the best path to improved diagnostic and therapeutic modalities in the care of these patients.

Port site metastasis of ovarian carcinoma remote from laparoscopic surgery for benign disease

BACKGROUND

The use of laparoscopic surgical procedures has continued to expand due to the many advantages that this surgical approach offers. However, as we continue to realize the benefits and expand the scope of laparoscopic procedures, new complications may occur.

CASE

This is the case of a 77-year-old gravida 2 para 2 who underwent exploratory laparotomy and surgical staging with optimal cytoreduction for Stage IIIC papillary serous ovarian carcinoma in February 1998. Her past surgical history was significant for total abdominal hysterectomy and left salpingo-oophorectomy in 1955 for symptomatic leiomyomata and for a laparoscopic cholecystectomy in July 1997. After initial platinum-based chemotherapy, she presented with an enlarging nodule at the right upper quadrant laparoscopic port site. Fine needle aspiration confirmed recurrent papillary serous ovarian carcinoma. After a discussion of her options, she elected to undergo surgical resection with postoperative salvage chemotherapy.

CONCLUSION

Port site recurrences have been previously reported in patients who underwent initial surgical evaluation for ovarian carcinoma utilizing the laparoscopic approach. However, it is unusual for recurrent cancer to appear in port sites or operative incisions not related to the initial cancer surgery. This report serves to caution the gynecologic oncologist that the first evidence of recurrence may be at a laparoscopic port site from prior benign gynecologic or nongynecologic surgery.