Chi-Feng Su

Primary non-Hodgkin's lymphoma of the uterus, cervix and parametrium treated by combined immunochemotherapy

Primary malignant lymphoma of the female genital tract is extremely rare and no standard treatment has been established. The present patient is menopausal with diffuse large B‐cell lymphoma of the uterine body, endocervix and parametrium. She underwent a simple total abdominal hysterectomy and bilateral salpingo‐oophorectomy, followed by treatment with a new regimen, combined immunochemotherapy with rituximab (monoclonal antibody), cyclophosphamide vincristine, and prednisolone. The patient had complete remission in the follow‐up 3 years after this therapy. We suggest this treatment is a useful therapy for a patient with primary malignant lymphoma of the uterine body.

Fetal acidosis from obstetric interventions during the first vaginal delivery.

OBJECTIVE The aim of this study was to analyze the blood gas values of umbilical cord blood in newborns of first vaginal deliveries with or without obstetric interventions. MATERIALS AND METHODS In a prospective descriptive study conducted during the 6-month period from August 2003 through February 2004 at a university hospital, we analyzed the umbilical cord blood gas results of 80 term newborns delivered vaginally from healthy nulliparous women. Multivariate logistic analysis was used to evaluate the associations between fetal acidosis (pH<7.20) and any obstetric interventions. RESULTS The mean of umbilical cord blood arterial pH was 7.26 (standard deviation, 0.072). After controlling for the confounding factors with multivariate logistic regression, fetal acidosis (pH<7.20) was found to be significantly associated with oxytocin augmentation (odds ratio [OR], 16.48; 95% confidence interval [CI], 1.21-226.1) and vacuum extraction (OR, 10.76; 95% CI, 1.025-112.9). In contrast, there was no significant relationship between fetal acidosis with episiotomy (OR, 1.096; 95% CI, 0.07-16.6) or epidural anesthesia (OR, 0.074; 95% CI, 0.003-2.09). CONCLUSION Oxytocin augmentation and vacuum extraction were significantly related to low cord arterial pH values (pH<7.20), but there were no adverse effects to the newborns of first vaginal deliveries.

A complicated hematometra and fallopian tubal occlusion in uterine didelphys with unilateral cervical atresia.

Uterine anomalies are uncommon Mullerian malformations without known etiology. Many hypotheses have been put forward to explain these anomalies such as the involvement of genetic, environmental, and pharmacological issues [1]. The incidence is reported to be between 0.5–5.0% of all women [2]. However, a congenital uterine anomaly involving cervical atresia is extremely rare. We report a patient, diagnosed with a uterine anomaly, who underwent a primary laparotomy for unilateral endometrioma without resectioning of the rudimentary horn. Postoperatively, the patient received 6 months of gonadotropin-releasing hormone agonist (GnRHa) treatment as a conservative therapy. After completion of the GnRHa therapy, endometriosis recurred and a hematometra developed. This occurred after her menstrual cycle had resumed for 3 months post GnRHa treatment. The patient underwent a second laparotomy and the rudimentary horn was resectioned. Recovery after the operation was uneventful. The final diagnosis of the uterine anomaly in this patient was uterine didelphys with unilateral cervical atresia. A 23-year-old nulligravid woman had complained of dysmenorrhea since menarche at the age of 14 years in 1999 and this had been partially relieved with medical management. At the age of 22 years during April 2007, the patient presented with acute abdominal pain in the left lower quadrant, in which an abdominal mass was palpable. Pelvic ultrasonography by a primary gynecologist revealed a 10 × 10 × 10 cm complex mass of the left adnexa with multiple cysts and septa. A bimanual pelvic examination showed a single vagina and single cervix. Computed tomography (CT) revealed a multicystic mass associated with the left ovary, possibly endometrioma, and two uterine horns indicating the possibility of a bicornuate uterus (Figures A and B). The right kidney was enlarged and the left kidney was absent. An elevated serum CA-125 level of 8,640 U/mL was noted. The patient underwent exploratory laparotomy by the primary gynecologist. The findings included a 10 cm left ovarian endometrioma, severe endometriosis involving the cul-de-sac and the pelvis, as well as layering of hemosiderin throughout the uterine horns, the pelvis and the omentum. Fibrous adhesions involving the sigmoid colon, small intestine and pelvic sidewall were also noted. The right uterine horn and the right fallopian tube were normal in appearance; a right ovary could also be identified. The uterine anomaly was thought to be a bicornuate uterus. Left partial oophorectomy and lysis of the adhesions were performed. The pathological findings revealed ovarian endometrioma and endometriotic cysts that had endometrial epithelium and hemosiderin-laden macrophages. Postoperatively, the patient recovered quickly and was prescribed 6 months of GnRHa therapy.

Uterine Anomalies with Ipsilateral Renal Agenesis

Summary Objective To describe the management of bicornuate uterus with ipsilateral renal agenesis. Case Report Two patients were diagnosed with bicornuate uterus and ipsilateral renal agenesis; one of which was identified as bicornuate unicollis. Both patients were successfully treated with metroplasty. In one patient, the central myometrium was found to extend to the level of the internal cervical os, suggesting bicornuate unicollis. Dysmenorrhea decreases during menstrual periods and there is no restriction on childbearing. Conclusion Bicornuate uterus carries the potential risks of back flow of menstrual secretion and ascending infection. Metroplasty is a valuable treatment for bicornuate uterus with a single cervix and vagina, and also prevents the back flow of menstruation which would otherwise progress to pelvic endometriosis.

Repeat midurethral sling treatment for prior midurethral sling failure

We reviewed articles in the PubMed database which describe the results and outcome of a repeat midurethral synthetic sling (MUS), known as tension-free vaginal tape (TVT), or transobturator tape/tension-free vaginal tape obturator for prior MUS failure in patients who presented with persistent or recurrent stress urinary incontinence (SUI). We combined or separated the keywords “TVT,” “failure,” “repeat TVT,” and “recurrent/persistent SUI.” The search was limited by publication data from 2000 to 2010, humans, female, and English text. A repeat TVT procedure treating prior TVT failure showed success rates ranging from 70% to 90%. The outcomes showed no significant differences between a repeat retropubic route or transobturator route. A repeat MUS procedure for persistent or recurrent stress urinary incontinence is a reliable option for patients with prior MUS failure.

PREDICTION OF NEWBORN BIRTH WEIGHT BASED ON THE ESTIMATION AT 20-24 WEEKS OF GESTATION

OBJECTIVE The aim of this study was to develop a mathematical equation to predict the birth weight during the second trimester at 20-24 weeks of gestation. MATERIALS AND METHODS In a university hospital, 110 healthy pregnant women were eligible for inclusion at 20-24 weeks of gestation. We recorded the maternal weight (pre-pregnancy, mid-pregnancy, and at delivery) and body mass index (BMI), newborn birth weight, time period from ultrasound examination to term delivery, and also the fetal biometrics sonographically at 20-24 weeks of gestation. Pearsons correlation was used to verify the extent of the relationship between all the above measurements and the newborn birth weight. Multiple regressions with the stepwise method were used to analyze maternal weight factors, fetal biometrical factors, and pregnancy interval. An equation for term birth weight estimation during the second trimester was determined. RESULTS Maternal BMI at mid-pregnancy, time interval from mid-pregnancy to term, and abdominal circumference had the highest correlation with newborn birth weight (r = 0.388, 0.341, and 0.315, respectively, p < 0.05). Using the stepwise regression analysis, an optimal formula with variance of 0.303 was derived: estimated birth weight = -700 + 49.766 × (mid-pregnancy BMI [kg/m2]) + 13.362 × (time interval from mid-pregnancy to term delivery [days]) + 68.696 × (abdominal circumference [cm]). CONCLUSION We propose an accurate, simple, and easy formula to better assess the newborn birth weight at mid-pregnancy for the Asian population. Mid-pregnancy BMI was a more significant factor for birth weight estimation than other maternal weight factors in this study.

Prenatal diagnosis of complete ring chromosome 22 without phenotypical abnormalities

A healthy 34-year-old, para 1, Taiwanese woman presented for genetic amniocentesis at 18 weeks of gestation due to advanced maternal age. Her previous medical history was unremarkable except for a cesarean delivery following prolonged labor with a failed induction. Prenatal ultrasonography did not detect any structural abnormalities, except for borderline ventriculomegaly (Fig. 1). The karyotype of amniotic fluid cell culture was identified as 46,XY,r(22)(p13q13) (Fig. 2), which was further confirmed by cord blood sampling. Following detailed consultation and nondirective genetic counseling with physicians, the patient and her husband chose to terminate the pregnancy via hysterotomy. The procedure was performed uneventfully at 21 weeks of gestation. A dead male fetus weighing 520 g was delivered from breech presentation without any significant phenotypical abnormalities (Fig. 3) and no structural anomalies were found in an autopsy. Fetal skin and umbilical cord cultures were used to confirm the initial karyotype report postdelivery. Ring chromosome 22 [r(22)] is a rare cytogenetic abnormality first identified by Weleber et al in 1968 [1]. Since that initial report, more than 60 cases have been described in medical literature. Ring chromosomes usually occur when a terminal break in both arms of the chromosome and the broken ends fuse together, or one broken chromosome end joins with the opposite telomeric region. This condition results in the loss of genetic material. Alternatively, ring chromosomes can be formed by the fusion of subtelomeric sequences or telomere-telomere fusion with no deletion, resulting in complete ring chromosomes. Ring chromosomes often lead to developmental anomalies but are

Suburethral Slingplasty Using a Self-fashioned Gynemesh for Treating Urinary Incontinence and Anterior Vaginal Wall Prolapse

OBJECTIVE This study was conducted to evaluate the effectiveness of self-fashioned Gynemesh for the concomitant treatment of urinary incontinence and anterior vaginal wall prolapse, and the factors involved in mesh erosion. MATERIALS AND METHODS From March 2004 to September 2006, 65 women with urinary incontinence, with or without pelvic organ prolapse or prior surgery for prolapse or incontinence, were recruited for this study. A self-fashioned Gynemesh was used for the concomitant treatment of urinary incontinence and anterior vaginal wall prolapse. Patients in this study underwent suburethral slingplasty and/or concomitant pelvic reconstructive operations. A general linear model univariate analysis was performed to assess the relationships between mesh erosion and various variables. RESULTS The mean postoperative follow-up was 33 months. Those patients with anterior wall prolapse presented as completely cured postoperatively. The cure rate for urinary incontinence was 80%, and the improvement rate was 17%. Vaginal mesh erosion was discovered in four patients (6%) during the postoperative follow-up. These four patients remained continent after the removal of the eroded mesh. The interactive effects for mesh erosion by a general linear model analysis were menopausal women with advanced anterior vaginal wall prolapse (p < 0.05) and women with advanced anterior vaginal wall prolapse with concomitant sacrospinous ligament fixation (p < 0.05). CONCLUSION We found that using self-fashioned Gynemesh for tension-free suburethral and anterior vaginal slingplasty provided a high success rate (97%) in the 3 years of follow-up. Mechanical rejection may be one of the causes of vaginal mesh erosion.

Primary Peritoneal Serous Papillary Carcinoma with Brain Metastasis: Case Report

Primary peritoneal serous papillary carcinoma (PPSC) should be treated as aggressively as advanced ovarian carcinoma is treated. A 55-year-old postmenopausal woman with PPSC and massive ascites was diagnosed by exploratory laparotomy. The patient was first treated with a six-cycle regimen (cyclophosphamide and cisplatin), then underwent debulking surgery which was then followed by another six-cycle regimen (paclitaxel and carboplatin). Mood changes, speech motor difficulties and a rapid increase in CA125 levels indicated PPSC with brain metastasis which was confirmed by magnetic resonance imaging. Topotecan (Hycamtin(superscript ®)) was prescribed as a salvage therapy and combined with brain radiation because topotecan can penetrate the blood-brain barrier. This treatment failed and the patient expired three months after the diagnosis of PPSC with brain metastasis.

Experience in Treatment of Patients with Gestational Trophoblastic Disease

Summary Objective To determine outcome in patients with hydatidiform mole and gestational trophoblastic tumor after successful treatment. Materials and Methods This was a retrospective review of outcome in 22 patients with gestational trophoblastic disease (GTD) who completed human chorionic gonadotropin (hCG) follow-up for 1 year or more after treatment between 1999 and 2003. Results The mean age of patients with GTD was 32.5 years. Sixteen patients (72.7%) with hydatidiform mole and six (27.3%) with gestational trophoblastic tumor were evaluated. One patient (4.5%) with metastatic choriocarcinoma experienced complete remission after debulking surgery followed by chemotherapy. Fifteen patients (68.2%) with persistent GTD were diagnosed by hCG follow-up. After at least 1 year, eight patients (36.4%) conceived and six (27.3%) delivered a healthy term baby. All patients experienced an excellent prognostic outcome following chemotherapy and there were no deaths. Conclusion GTD exhibited an excellent response to chemotherapy and subsequent successful pregnancy was achieved in some patients 1 year or more after completion of treatment. Patients without previous childbirth desired subsequent pregnancy. Patients must be followed-up carefully after treatment and during conception.