Candiani et al.

After the section we did not insert an intrauterine contraceptive device nor did we administer estrogens inasmuch as in a previous study we had found these measures of no benefit. 11 Postoperative morbidity was negligible in both groups. We observed no differences in the intracavitary morphologic results after metroplasty with the argon laser compared with microscissors. The follow-up of the patients is too short to draw conclusions on the reproductive outcome. As a secondary observation we found that the data obtained at the follow-up ultrasonographic examination corresponded to those of the "second look" hysteroscopy. If this finding is confirmed, it would mean that an ultrasonographic scan with half-full bladder6 ,7 would be sufficient to check the results of surgery before allowing patients to try to conceive. Hysteroscopy could be reserved for patients who require correction of deep septal remnants. This study confirmed that microscissors are the most simple, rapid, effective, and economic instrument for hysteroscopic correction of a septate uterus. Other disadvantages of the argon laser include the necessity for running water to cool the laser generator and for a special three-phase electricity supply. The eye safety filter necessary to protect the operator's retina from backscatter alters color perception, reduces the field of view, adds an extra encumbrance to the eyepiece of the hysteroscope, and makes photographic or television documentation of the operation difficult. It takes longer to learn to use the argon laser than microscissors in hysteroscopy. Lastly, an argon laser has a very high initial cost and should be acquired only by hospitals that can

January 1991 Am J Obstet Gynecol

amortize the expense on a large number of endoscopic operations. Otherwise the economic advantage of hysteroscopic metroplastt is lost.

REFERENCES 1. Valle RF, Sciarra JJ. Hysteroscopic treatment of the septate uterus. Obstet Gynecol 1986;67:253-7. 2. March CM, Israel R. Hysteroscopic management of recurrent abortion caused by septate uterus. AM J OBSTET GYNECOL 1987;156:834-42. 3. Daly DC, Maier D, Soto-Albors C. Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 1989;73: 201-5. 4. De Cherney AH, Russell JB, Graebe RA, Polan MC. Resectoscopic management of mullerian fusion defects. Fertil Steril 1986;45:726-8. 5. DaniellJF, Osher S, Miller W. Hysteroscopic resection of uterine septi with visible light laser energy. Colposc Gynecol Laser Surg 1987;3:217-20. 6. Candiani GB, Ferrazzi E, Fedele L, Vercellini P, Dorta M. Sonographic evaluation of uterine morphology: a new scanning technique. Acta Eur Fertil 1986;17:345-7. 7. Fecide L, Ferrazzi E, Dorta M, Vercellini P, Candiani GB. Ultrasonography in the differential diagnosis of "double" uteri. Fertil SterilI988;50:361-4. 8. The American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, miillerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944-55. 9. Keye WR. Laparoscopic treatment of endometriosis. Obstet Gynecol Clin North Am 1989;16:157-66. 10. Baggish MS, Baltoyannis P. New techniques for laser ablation of the endometrium in high-risk patients. AM J OBSTET GYNECOL 1988;159:287-92. 11. Vercellini P, Fedele L, Arcaini L, Rognoni MT, Candiani GB. Value of intrauterine device insertion and estrogen administration after hysteroscopic metroplasty. J Reprod Med 1989;447-50.

Angiosarcoma of the uterus: A case report Guillermo E. Quinonez, MD, MSc, Maria P. Paraskevas, MD, MSc, Malkit S. Diocee, EMT, and Susan M. Lorimer, MD Winnipeg, Manitoba, Canada We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstration of Weibel-Palade bodies in the tumor cells. Only 10 cases of this entity have been previously documented in the literature. (AM J OBSTET GVNECOL 1991;164:90-2.)

Key words: Uterine angiosarcoma, Weibel-Palade bodies

From the Department of Pathology, Health Sciences Centre, Faculty of Medicine, University of Manitoba. Received for publication July 30, 1990; accepted August 8, 1990. Reprint requests: G. Quinonez, MD, 820 Sherbrook St., Winnipeg, Manitoba, Canada R3A 1R9.

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Angiosarcomas of the uterus are rare. Ten cases have been previously documented in the literature. I, 2 We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstrating Weibel-Palade bodies.

Volume 164 Number I, Part I

Uterine angiosarcoma

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Fig. 1. Weibel-Palade body is seen at center of figure (a1Tow). Micropinocytotic vesicles and long cytoplasmic extensions from neighboring cells are also seen. Intermediate junctions are present between those extensions (center, upper part). (x 36,000.)

Case report

A 65-year-old woman presented to her family physician in April 1985 with postmenopausal bleeding. A curettage was performed, and findings were interpreted as angiosarcoma. Results of endocervical curettage were noncontributory. Gynecologic history included menarche at age 14 and normal regular menses. She was gravida 3, para 3 and had uneventful vaginal deliveries. She had had two previous curettages because of peri menopausal bleeding in 1967 and postmenopausal bleeding in 1982. Results of both curettages were reported as unremarkable. Two months before this hospital admission, she noted increasing fatigue and a IO-pound weight loss over the last 2 weeks. A general physical examination showed her condition to be essentially normal. Pelvic examination showed a brownish red discharge from the endocervix. The uterus was bulky and measured approximately 7.5 em in length. Adnexal and rectal examinations gave negative results. Findings on intravenous pyelography and barium enema were negative. The hemoglobin level was 116 mg/L, white blood cell count was 8000/ml, and platelet count was 298,OOO/ml. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and selective pelvic lymphadenectomy followed by vaginal insertion of cesium and nine courses of combination chemotherapy with cisplatin and Adriamycin. At the last follow-up visit in March 1989, the patient was clinically free of disease. A vaginal smear showed no abnormal

cells and the chest x-ray film did not show any abnormalities. Tissue received at the laboratory consisted of uterus with adnexa, right and left pelvic nodes, and omental biopsy specimen. The uterus weighed 100 gm. The endometrial cavity measured 3.5 x 2.4 em. Arising from the anterior aspect of the uterus, toward the fundus, was a large hemorrhagic mass measuring 4.7 x 4 em and raised 1.9 em above the endometrial layer. On section, this mass had a gray hemorrhagic appearance and a finely lobulated pattern. An additional satellite nodule measuring 0.9 em in diameter was present posteriorly at the fundus, toward the right cornu. Tubes and ovaries were atrophic and otherwise unremarkable. Microscopic sections of the hysterectomy specimen showed an endometrial tumor similar to the reviewed curettage specimen. It consisted mostly of solid masses of pleomorphic and spindle cells forming communicating channels filled with blood. The nuclei were irregular and hyperchromatic with occasional nucleoli, and the cytoplasm was eosinophilic with no obvious cytoplasmic borders; mitoses were up to 6 per 10 highpower fields. True blood vessels were not found within the tumor. Reticulin stain showed abundant reticulum network outlining interconnecting spaces. The tumor infiltrated the myometrium irregularly and extended to half its thickness. The satellite nodule showed similar histologic features. The remaining endometrium showed only cystic and atrophic glands. Pelvic nodes and omentum were free of tumor.

Quinonez at al.

Ultrastructurally, cells lining the vascular spaces showed micropinocytotic vesicles and, not infrequently, Weibel-Palade bodies (Fig. I). Factor VIII-related antigen immunocytochemical stain was negative in the tumor cells. Comment

The present case was that of a 65-year-old woman presenting with postmenopausal bleeding who underwent surgical treatment and chemotherapy after diagnosis of angiosarcoma of the uterus. She was doing well 4 years after operation. This clinical history is similar to some of the cases previously reported. 1.2 This case showed, by light microscopy, typical features of a vascular tumor, the pattern of which was well demonstrated by reticulin stain. The true vascular nature of the tumor was confirmed by demonstrating Weibel-Palade bodies in the tumor cells ultrastructurally. An immunocytochemical test for Factor VIII-

January 1991 Am J Obslel Gynecol

related antigen gave negative results. A negative result of Factor VIII-related antigen staining does not rule out the diagnosis of angiosarcoma since Factor VIIIrelated antigen positivity is highly variable in cases of angiosarcoma (65% to 95%). This report adds a new case of this extremely rare entity. It confirms ultrastructurally, for the first time in a published case, the vascular nature of the neoplasm by demonstrating Weibel-Palade bodies in the tumor cells. We thank Dr. A. Alguacil-Garcia for his comments. REFERENCES 1. Ongkasuwam C, Taylor JE, Tang C, Prempree T. Angiosarcomas of the uterus and ovary: clinicopathologic report. Cancer 1982;49:1469-75. 2. Whitkin GB, Askin FB, GeratzJD, Reddick RL. Angiosarcoma of the uterus: a light microscopic, immunohistochemical, and ultrastructural study. Int J Gynecol Pathol 1987;6:2: 176-84.

Quantitative and qualitative platelet abnormalities during pregnancy Helen Y. How, MD, Frauke Bergmann, MD, Mabel Koshy, MD,Juan Chediak, MD, Celeste Presperin, RN, and Stanley A. Gall, MD Chicago, Illinois In a 1-year period, 15 of 4048 pregnant women were found to have thrombocytopenia during their first prenatal visit. Their qualitative and quantitative platelet abnormalities were followed up prospectively for 1 to 6 months post partum. Platelet counts returned to normal in 14 of 15 patients 4 to 6 weeks post partum. von Willebrand factor antigen and ristocetin cofactor activity were low in three of 15 patients 4 to 6 weeks post partum, but had been normal dUring the antepartum period. Two of these three patients had prolonged bleeding times ante partum and post partum. All three patients subsequently were found to have mild type I von Willebrand disease. Six patients had detectable platelet antibodies. Neonatal thrombocytopenia was found in one term infant of a patient with mild thrombocytopenia and negative platelet antibodies. This study suggests that mild, transient, isolated thrombocytopenia can occur in an otherwise normal pregnancy and its incidence may be lower than previously reported. Extensive testing is not indicated unless there is an associated prolonged bleeding time. The possibility of von Willebrand disease or a qualitative platelet disorder should be considered. (AM J OBSTET GVNECOl 1991 ;164:92-8.)

Key words: Thrombocytopenia, pregnancy, von Willebrand disease

From the Department of Obstetrics and Gynecology and Division of Hematology 1Department of Medicine, University of Illinois at Chicago, and Michael Reese Hospital. Supported in part by Grant BE 112011-2, Deutsche Forschungsgemeinschaft, and by the Walter A. Gatz.ert Coagulation Research Fund. Receivedfor publication March 30, 1990,. revised August 10, 1990; accepted August 13, 1990. Reprint requests: Helen How, MD, University of Louisville School of Medicine, Department of Obstetrics and Gynecology, Louisville,

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Mild, transient, isolated thrombocytopenia has been reported to occur during pregnancy with a frequency of 7.6% to 24%. I, 2 Postulated causes of this transient mild thrombocytopenia include immune complex deposition on platelets during a viral infection with removal from circulation,1 chronic intravascular coagulation during normal pregnancy,' and the "tail end" of a normal platelet distribution.' All re-

Angiosarcoma of the uterus: a case report.

We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstration of Weibel-Palade bodies ...
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