Yu-Che Ou

Clinical characteristics of perforated pyometra and impending perforation: Specific issues in gynecological emergency

Objective:u2002 To evaluate the clinical characteristics of pyometra and the differences between perforated pyometra and early‐drained pyometra in order to prevent morbidity.

Disseminated peritoneal tuberculosis simulating advanced ovarian cancer: A retrospective study of 17 cases

OBJECTIVESnThe abdominopelvic cavity is one of the common sites for extrapulmonary tubercular infections. The rate of preoperative misdiagnoses between peritoneal tuberculosis (TB) and ovarian cancer is high because of overlapping nonspecific signs and symptoms. We attempted to analyze the experience within our hospital so as to establish the best means of discriminating between peritoneal TB and advanced ovarian cancer.nnnMETHODSnSeventeen patients diagnosed as having peritoneal TB between July 1986 and December 2008 at the Obstetrics and Gynecology Department of our hospital with the initial presentation simulating advanced ovarian cancer were retrospectively reviewed and evaluated.nnnRESULTSnPatients ages ranged from 24 years to 87 years (median, 38 years). Ten of 17 patients (60%) were younger than 40 years. All patients except one had elevated serum cancer antigen-125 levels with a mean of 358.8 U/mL (range, 12-733 U/mL). Computed tomographic (CT) scans showed ascites with mesenteric or omental stranding in all (100%), enlarged retroperitoneal lymph nodes in six (35.3%), and an adnexal mass in three (17.6%). Abdominal paracentesis was performed in seven cases, in which the findings revealed lymphocyte-dominant ascites without malignant cells. Surgical intervention by laparotomy was performed in 13 cases (76%) and by laparoscopy in three cases (18%), and a CT-guided peritoneal biopsy was performed in one case (6%). A frozen section was taken from 16 patients but not the patient who received a CT-guided peritoneal biopsy, and all revealed granulomatous inflammation. A final pathological examination confirmed a diagnosis of peritoneal TB. All patients responded to anti-TB treatment.nnnCONCLUSIONSnIn view of these data, a clinical diagnosis of peritoneal TB should be considered in a relatively young female with nonspecific symptoms of abdominal distension and wasting, as well as lymphocytic ascites without malignant cells. Laparoscopy or a minilaparotomy to obtain tissue samples for frozen-section analysis may be the most direct and least-invasive approach for a diagnosis, thus avoiding unnecessary extended surgery in these patients.

Pretreatment carcinoembryonic antigen level is a risk factor for para-aortic lymph node recurrence in addition to squamous cell carcinoma antigen following definitive concurrent chemoradiotherapy for squamous cell carcinoma of the uterine cervix

BackgroundTo identify pretreatment carcinoembryonic antigen (CEA) levels as a risk factor for para-aortic lymph node (PALN) recurrence following concurrent chemoradiotherapy (CCRT) for cervical cancer.MethodsFrom March 1995 to January 2008, 188 patients with squamous cell carcinoma (SCC) of the uterine cervix were analyzed retrospectively. No patient received PALN irradiation as the initial treatment. CEA and squamous cell carcinoma antigen (SCC-Ag) were measured before and after radiotherapy. PALN recurrence was detected by computer tomography (CT) scans. We analyzed the actuarial rates of PALN recurrence by using Kaplan-Meier curves. Multivariate analyses were carried out with Cox regression models. We stratified the risk groups based on the hazard ratios (HR).ResultsBoth pretreatment CEA levels ≥ 10 ng/mL and SCC-Ag levels < 10 ng/mL (p < 0.001, HR = 8.838), SCC-Ag levels ≥ 40 ng/mL (p < 0.001, HR = 12.551), and SCC-Ag levels of 10-40 ng/mL (p < 0.001, HR = 4.2464) were significant factors for PALN recurrence. The corresponding 5-year PALN recurrence rates were 51.5%, 84.8%, and 27.5%, respectively. The 5-year PALN recurrence rate for patients with both low (< 10 ng/mL) SCC and CEA was only 9.6%. CEA levels ≥ 10 ng/mL or SCC-Ag levels ≥ 10 ng/mL at PALN recurrence were associated with overall survival after an isolated PALN recurrence. Pretreatment CEA levels ≥ 10 ng/mL were also associated with survival after an isolated PALN recurrence.ConclusionsPretreatment CEA ≥ 10 ng/mL is an additional risk factor of PALN relapse following definitive CCRT for SCC of the uterine cervix in patients with pretreatment SCC-Ag levels < 10 ng/mL. More comprehensive examinations before CCRT and intensive follow-up schedules are suggested for early detection and salvage in patients with SCC-Ag or CEA levels ≥ 10 ng/mL.

Primary fallopian tube carcinoma: Clinicopathological analysis of 12 cases

OBJECTIVEnPrimary fallopian tube carcinoma is one of the least common gynecological cancers and is difficult to diagnose preoperatively. We aimed to analyze the clinicopathological characteristics of this rare disease and to identify the prognostic factors predicting prognosis.nnnMATERIALS AND METHODSnTwelve cases of primary fallopian tube carcinoma that had been diagnosed and treated in Kaohsiung Chang Gung Memorial Hospital between July 1986 and December 2005 were retrospectively reviewed. Factors, including age, gravidity, parity, stage, surgical intervention, pathological findings, relapse, and survival, were analyzed.nnnRESULTSnThe median age of the 12 cases was 54 years (range, 32-67 years), whereas the median follow-up time was 38 months. None of the 12 cases were diagnosed preoperatively. Preoperative diagnoses were adnexal mass of unknown nature in six (50%), tubo-ovarian abscess in three (25%), ovarian carcinoma in two (16.7%), and endometrioma in one (8.3%) cases. Two patients (16.7%) had experienced the typical symptom of watery vaginal discharge. Three patients (25%) were in Stage I, three (25%) in Stage II, four (33.3%) in Stage III, and two (16.7%) were unstaged. Nine patients had received postoperative platinum-based adjuvant chemotherapy. The 5-year disease-free survival rate was 64%. On evaluating the correlation between clinicopathological parameters and survival, only the Federation of Gynecology and Obstetrics stage (p=0.017) was a significant prognostic factor.nnnCONCLUSIONnAlthough preoperative diagnosis of fallopian tube carcinoma is difficult, still 16.7% of our patients experienced the typical symptom suggestive of tubal carcinoma. Prognostic factors associated with fallopian tube cancer were similar to those of epithelial ovarian cancer.

Prognostic Value of Pretreatment Carcinoembryonic Antigen After Definitive Radiotherapy With or Without Concurrent Chemotherapy for Squamous Cell Carcinoma of the Uterine Cervix

PURPOSEnTo evaluate whether pretreatment carcinoembryonic antigen (CEA) levels have a prognostic role in patients after definitive radiotherapy for squamous cell carcinoma (SCC) of the uterine cervix.nnnMETHODS AND MATERIALSnA retrospective study of 550 patients was performed. The SCC antigen (SCC-Ag) and CEA levels were regarded as elevated when they were ≥2 and ≥5 ng/mL, respectively. A total of 208 patients underwent concurrent chemoradiotherapy (CCRT). The Kaplan-Meier method was used to calculate the distant metastasis (DM), local failure (LF), disease-free survival (DFS), and overall survival (OS) rates. Multivariate analysis was performed using the Cox proportional hazards model. The hazard ratio (HR) with 95% confidence interval (CI) was evaluated for the risk of a poor prognosis.nnnRESULTSnCompared with the patients with normal CEA/SCC-Ag levels, CEA levels ≥10 ng/mL but without elevated SCC-Ag levels was an independent factor for LF (HR, 51.81; 95% CI, 11.51-233.23; p < .001), DM (HR, 6.04; 95% CI, 1.58-23.01; p = .008), DFS (HR, 10.17; 95% CI, 3.18-32.56; p < .001), and OS (HR, 5.75; 95% CI, 1.82-18.18; p = .003) after RT alone. However, no significant role for CEA was noted in patients with SCC-Ag levels ≥2 ng/mL. In patients undergoing CCRT, a CEA level ≥10 ng/mL was an independent factor for LF (HR, 2.50; 95% CI, 1.01-6.21; p = .047), DM (HR, 3.41; 95% CI, 1.56-7.46; p = .002), DFS (HR, 2.73; 95% CI, 1.39-5.36; p = .003), and OS (HR, 3.93; 95% CI 1.99-7.75; p < .001). A SCC-Ag level of ≥40 ng/mL was another prognostic factor for DM, DFS, and OS in patients undergoing not only CCRT, but also RT alone. The 5-year OS rate for CCRT patients with CEA <10 ng/mL and ≥10 ng/mL was 75.3% and 35.8%, respectively (p < .001). CCRT was an independent factor for better OS (HR, 0.69; 95% CI, 0.50-0.97; p = .034).nnnCONCLUSIONnPretreatment CEA levels in patients with SCC of the uterine cervix provide complementary information for predicting LF, DM, DFS, and OS, except for in patients with abnormal SCC-Ag levels before RT alone. More aggressive therapy might be advisable for patients with CEA levels of ≥10 ng/mL.

Sepsis secondary to cesarean scar diverticulum resembling an infected leiomyoma.

Cervical diverticulum is a very rare anomaly and has also been called pregnancy-associated sacculations [1] and previous cesarean delivery scar (PCDS) defect and may impair the drainage of menstrual flow through the cervix producing an accumulation of blood in the pouch. Most reported cases described the presence of a hiatus or diverticulum on the anterior isthmus at the site of a PCDS and only three cases were considered true uterine diverticula [1]. Uterine abscess or pyometra is uncommon and is thought to occur as a result of interference with the natural drainage of the uterus. It is commonly caused by malignant or benign gynecological tumors, radiation cervicitis, atrophic cervicitis, congenital anomalies, and intrauterine device (IUD). We herein describe the first case of PCDS diverticulum complicated by sepsis secondary to abscess formation. A 41-year-old gravida 2 para 2 was seen with complaints of intermittent fever and progressive lower abdominal pain for 2 weeks. Her history was significant for two cesarean deliveries, an IUD in place for 3 years, pelvic inflammatory disease 5 years previously, and recurrent urinary tract infection in the recent 6 months. Additionally, a lower corpus uterine mass of about 3 cm in diameter was noted 3 years prior, and she experienced postmenstrual spotting occasionally. On admission, her body temperature was 38.4 C. A palpable mass over the lower anterior aspect of the uterus, profuse odorless vaginal discharge, and cervical motion tenderness were noted on pelvic examination. The abdomen was soft, but mild tenderness without rebounding pain was noted over the lower abdomen. Abdominal ultrasonography revealed a fluidfilled mass over the anterior wall of the uterus and an IUD in the uterine cavity (Fig. 1). Laboratory results revealed an elevated

Difficulty in diagnosis and different prognoses between colorectal cancer with ovarian metastasis and advanced ovarian cancer: An empirical study of different surgical adoptions

OBJECTIVEnTo determine the clinical manifestations and optimal management of female patients with advanced colorectal cancer (CRC) metastasis in ovaries mimicking advanced ovarian malignancy.nnnMATERIALS AND METHODSnA retrospective medical records review of female patients with primary CRC metastasis to ovaries, which were initially diagnosed as ovarian malignancy, and treated between 2001 and 2013. Clinical presentations, pathologic findings, and treatment outcomes were analyzed.nnnRESULTSnIn total, 19 cases were collected in the study through a hospital tumor registry. The mean age of the patients at the time of diagnosis was 45 years (range, 28-63 years). The most common symptoms were abdominal pain or increased abdominal girth (63%). None of them had rectal bleeding. The ratio of cancer antigen-125 to carcinoembryonic antigen was available in 13 out 19 patients (less than 25 in 76.9%). Barium enema or colonoscopic exam was only performed in 10 outpatients. None of them had a positive finding. All 19 patients went for surgery, all of them had ovarian metastasis but only eight of them had bilateral involvement, and 14 of them had carcinomatosis. All patients went for either optimal cytoreduction surgery or suboptimal cytoreduction surgery. The patients who received optimal cytoreduction surgery had a significant better progression-free and overall survival than those who did not.nnnCONCLUSIONnClinical manifestations of primary CRC with ovarian metastasis may be confused with advanced ovarian cancer. Negative barium enema or colonoscopic exam cannot rule out the possibility of CRC. For patients with a cancer antigen-125 to carcinoembryonic antigen ratio less than 25, 76% are good reference of CRC metastasis to ovaries. Optimal cytoreduction surgery like that used for treating advanced ovarian cancer had a better prognosis than suboptimal cytoreduction colorectal cancer treatment.

The use of weekly topotecan in the treatment of heavily pretreated recurrent epithelial ovarian and primary peritoneal cancer: The Kaohsiung Chang Gung experience

OBJECTIVEnWe attempted to investigate the safety and efficacy of alternative weekly topotecan dosing in a heavily pretreated Taiwanese population with recurrent epithelial ovarian cancer (EOC) and primary peritoneal carcinoma (PPC).nnnMATERIALS AND METHODSnWe retrospectively reviewed the medical records of patients with recurrent EOC and PPC who had been treated with weekly topotecan between November 2008 and May 2012. Topotecan was given at a dose of 2.75-4 mg/m(2) via a 30-minute intravenous (IV) infusion on Days 1, 8, and 15 of a 28-day cycle until disease progression or unacceptable toxicity occurred.nnnRESULTSnThirty-two patients were identified and 24 (75%) of them had received at least two previous regimens of chemotherapy; the median number of treatment courses was seven. The main toxicities (Grades 3 and 4) were anemia in seven (21.9%), neutropenia in six (18.8%), and thrombocytopenia in two patients (6.2%). No deaths were attributable to the therapy. Overall, seven patients (21.9%) showed a partial response (PR), while seven patients (21.9%) with stable disease (SD) were observed. Furthermore, we found a favorable response and toxicity profile in patients who received the lowest dose intensity (2.75 mg/m(2)). The median progression-free survival (PFS) and overall survival (OS) were 3 months [95% confidence interval (CI) 2.7-3.2] and 20 months (95% CI 11.1-28.9), respectively.nnnCONCLUSIONnTopotecan administered as a weekly dosage (2.75-4 mg/m(2)) seems to be a tolerable regimen with modest activity in a Taiwanese population. Although the lower dose schedule showed a higher response with a better toxicity profile, further studies with more cases are needed to confirm this finding.

Prognostic role of excision repair cross complementing-1 and topoisomerase-1 expression in epithelial ovarian cancer.

OBJECTIVEnEpithelial ovarian cancer is the most lethal gynecologic cancer worldwide and chemoresistance is one of the major causes of treatment failure. We investigated whether ERCC1, TAU, TOPO2A, TOPO1, P53, and C-MYC expression could be used as predictors for treatment outcomes.nnnMATERIALS AND METHODSnImmunohistochemical staining was used to examine the expression of these biomarkers in resected tumor specimens from 38 patients treated in our institute. Clinicopathological data including demographics, staging, histological type, treatment response, expression of the biomarkers, and patient outcomes were analyzed.nnnRESULTSnThe median follow-up period was 47.5xa0months (range, 10-135xa0months) and the median overall survival was 56.0xa0months. Patients who did not have expression of ERCC1, and those who had expression of TOPO1 had significantly better overall survival. Cox regression analysis also confirmed that these two biomarkers were significant independent factors predicting survival (ERCC1, hazard ratio 5.51, 95% confidence interval: 2.02-14.00, pxa0=xa00.001; TOPO1, hazard ratio 0.22, 95% confidence interval: 0.06-0.77, pxa0=xa00.017).nnnCONCLUSIONnWe concluded that poor overall survival was significantly associated with positive ERCC1 and negative TOPO1 expression. The results might be the consequence of chemoresistance to platinum and camptothecins, both of which are commonly used regimens in the treatment of epithelial ovarian cancer.

Impact of treatment time-related factors on prognoses and radiation proctitis after definitive chemoradiotherapy for cervical cancer

This study aimed to investigate the impact of treatment time‐related factors on outcomes and radiation proctitis in patients undergoing concurrent chemoradiotherapy (CCRT) for cervical cancer. From September 2001 to December 2012, 146 patients with stage IIB cervical squamous cell carcinoma treated with CCRT were reviewed from a prospective cohort. Patients who received the same dose (45 Gy) of external beam radiation therapy (EBRT) were included in the analysis (n = 125). The same equivalent dose of 2 Gy (EQD2) of high‐dose‐rate intracavitary brachytherapy (HDR‐ICBT) was delivered at either 4 fractions of 6 Gy or 6 fractions of 4.5 Gy. The effects of the overall treatment time (OTT) and interval between EBRT and HDR‐ICBT on the cancer‐specific survival (CSS), local recurrence (LR), and incidence of proctitis were compared. The treatment time‐related factors did not adversely affect the CSS and LR rates. The multivariate analyses did not identify the OTT as an independent factor of CSS (P = 0.839) and LR (P = 0.856). However, OTT ≤56 days (P = 0.026) was identified as the only independent factor of overall proctitis. The 5‐year Grade 2 or greater proctitis rates were 14.9% and 0% (P = 0.001) in patients with the EBRT to ICBT interval ≤5 days and >5 days, respectively. To reduce rectal damage without compromising prognosis, the gap between EBRT and HDR‐ICBT should exceed 5 days in cervical cancer patients undergoing CCRT. Strictly limiting the OTT to 56 days may result in radiation proctitis without improvements in prognosis.