--
Myer S. Bornstein, MD, MMM, FACOG, FACPE, CPE
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
dean@thehuffpeople.net
Sent: Thursday, July 29, 2004 3:19 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: GYN: Mouse antibodies/HCG -- Now choriocarcinoma
..
Talk about treating without an established diagnosis ...
About 12 years ago I had a patient transferred in with Legionnaire's
Disease.
She was pregnant.
Chest x-ray failed to show any infiltrates, but it did show a very large
tumor.
With this being an otherwise healthy 30 year old 36 week pregnant patient,
my
first thought was that the names got mixed up on the x-ray plate. After
seeing
the tumor on a repeat chest x-ray, I concluded that the mass was real.
A serum HCG was obtained and it was 1.5 million. This established a probable
diagnosis. The patient went into spontaneous labor and we made no attempt to
stop it. Since I was to be off call by the time of the delivery, I
instructed
the residents to be sure to send the placenta to pathology. She delivered
that
night.
Two days later, I called pathology in the morning to find out what the
report
showed on the placenta. The pathologist said that it showed normal,
unremarkable placenta. I commented that this was really strange since we had
expected a choriocarcinoma. The pathologist responded that nobody told her
to
look for that diagnosis -- the pathology form said only "placenta".
She told me that she would look further at the placenta and call me back
later.
About an hour later I got a call from her. She said that on close
inspection,
the surfact of the placenta had a sand-paper like feel and that she had
taken
multiple permanent sections and a few frozen sections. The frozen sections
showed choriocarcinoma.
I wonder whether or not the diagnosis would have been made if I had not been
called. The placenta would have been disposed of in a few days. Maybe doing
additional cuts of the sections that had been collected might have yielded
the
diagnosis. Maybe not.
An important lesson here is that the interaction between pathologist and
clinician is not a contest or a guessing game whereby the pathologist is
given
the absolute minimum of information and is expected to come up with the
diagnosis. Something as simple as "suspect choriocarcinoma -- call me" might
have made a world of difference in this case.
- - - -
Quoting "Garry E. Siegel, M.D." <garrys@mindspring.com>:
> One more thing--I've seen a few case reports (malpractice ones) about
> giving chemo with an incorrect diagnosis of a trophoblastic tumor. While
> it wasn't a simple shot of methotrexate, I'm not ready to administer
> until this is fully investigated.
>
> Garry
>
> Robert:
>
> No doubt an abnormal pregnancy IF a pregnancy.
>
> I spoke with local hospital lab tech last night--she was familiar with
> this and suggests a UCG.
>
> This AM, UCG negative (HCG was 150 2 days ago, stable for 3 weeks).
>
> Hospital #1 lab guy suggests using their HCG machine--methodology to
> reduce cross reactivity. Hospital #2 lab girl says the same on their
> machine.
>
> Reference lab guy called and hasn't a clue, but the medical director is
> to call. Their catalog of tests offers a mouse antibody test.
>
> Once I hear from the lab doc, I'll likely send off the mouse test AND a
> hospital HCG.
>
> Garry
>
> At Wed, 28 Jul 2004, RModugno@aol.com wrote:
> >
> >In a message dated 7/27/2004 6:07:01 PM Eastern Standard Time,
> >garrys@mindspring.com writes:
> >I have inherited a case to deal with while my partner is on vacation;
> >details sketchy.
> >
> >32 YO P0 with positive UCG 7/8 in office, 7/8 spotted, HCG 150 approx.,
> >progesterone 1.7. Had "menses" for a few days, and now is not bleeding,
> >asymptomatic, and still is running HCGs around 144 to 150 (all in the
> >same lab).
> >
> >While I don't know this for sure, I have no doubt that she has been
> >examined and it was benign. Ultrasound 7/23--empty uterus, normal
> >adnexa, trace free fluid.
> >
> >Is this a case where mouse antibodies might help?
> >Use a different lab (waiting to talk to the lab supervisor in one
> >hospital about this)?
> >Could this be a chronic ectopic?
> >Should I empty her uterus and go from there?
> >
> >The lab tech today (after 5 PM)at the hospital immediately suggested
> >doing a urine pregnancy test, and that is planned tomorrow. However, I
> >didn't realize that she had been positive in the UCG on 7/8.
> >
> >Any thoughts?
> >
> >Garry
> >Abnormal pregnancy. A shot of methotrexate couldn't hoit!
> >Emptying an 'empty" uterus will complicate things and if it's empty -
then
> >what?
> >
> >Robert Modugno MD MBA FACOG
> >Marietta, GA
> >http://www.novaobgyn.yourmd.com
>
> --
> Garry E. Siegel, M.D.
> Private Practice
> Roswell, GA
>
