Re: GYN: Mouse antibodies/HCG -- Now choriocarcinoma
From: art fougner, md (evsono@pipeline.com)
Fri Jul 30 08:10:27 2004
Rich ...
the "Cool Hand Luke" phenomenon - "What we have here is a failure to
communicate."
art
At Thu, 29 Jul 2004, Richard Chudacoff, MD wrote:
>
>..
>
>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
>>
--
art fougner, md
ich bin ein New Yorker
