The correlation of acute toxicity and late rectal injury in radiotherapy for cervical carcinoma: evidence suggestive of consequential late effect (CQLE).

PURPOSE: To correlate the acute toxicity during pelvic irradiation and the development of late rectal injury following radiation therapy for cervical carcinoma. METHODS AND MATERIALS: Two hundred and twenty patients treated with curative-intent radiation therapy between November 1987 and January 1992 were analyzed. Patients were treated initially with external beam irradiation, 40-44 Gy/20-22 fractions to whole pelvis, followed by high dose rate intracavitary brachytherapy, 7.2 Gy to point A for 3 fractions. Severity of diarrhea during radiation therapy was scored according to six criteria: fecal characteristics, frequency, onset, prescription of antidiarrheal agents, body weight loss during irradiation, and extramedical care needed. Patients were categorized as group ND (no obvious diarrhea), group MD (moderate diarrhea), and group SD (severe diarrhea) for sum score 0-1, 2-5, and > or = 6, respectively. The rate of radiation proctitis was expressed, analyzed, and compared with actuarial proctitis-free rate and prevalence. RESULTS: 1) According to the score, 76 (35%), 89 (40%), and 55 (25%) patients were categorized as group ND, group MD, and group SD, respectively. Distribution of patients and treatment characteristics among the three groups appeared similar. Patients treated with a larger field size, > or = 16.5 cm2, tended to have increased severity of diarrhea. 2) Overall, 103 patients (47%, 103 of 220) developed radiation proctitis. Twenty-one patients were in group ND (28%, 21 of 76), 43 in group MD (48%, 43 of 89), and 39 in group SD (71%, 39 of 55). 3) The five-year actuarial proctitis-free rate was 72, 52, and 29% for group ND, MD, and SD, respectively (p < 0.005). 4) Taking time evolution and recoverability into account, the effect of diarrhea on the prevalence of radiation proctitis remained statistically significant at the first through the fourth year after irradiation. 5) Severity of radiation proctitis and severity of diarrhea were not correlated (Spearman's rank correlation coefficient r(s) = 0.229, p = 0.098). 6) Cox's multivariate analysis revealed that severity of diarrhea was the only factor that significantly correlated with the development of radiation proctitis. CONCLUSION: Patients with increased acute toxicity and diarrhea during radiation therapy of cervical carcinoma significantly increased the risk of late rectal injury. This result suggested that early excessive damage of acute-responding component of rectal wall may play an important role in the initiation of late rectal injury. Radiation proctitis can be accounted, in part, as a consequential late effect.

High-dose-rate intracavitary brachytherapy (HDR-IC) in treatment of cervical carcinoma: 5-year results and implication of increased low-grade rectal complication on initiation of an HDR-IC fractionation scheme.

PURPOSE: To report the treatment results and rectal/bladder complications of cervical carcinoma radically treated with high-dose-rate intracavitary brachytherapy (HDR-IC). The current policy of using three-fraction scheme was examined. METHODS AND MATERIALS: Between November 1987 and August 1990, 173 patients with cervical carcinoma were treated with curative-intent radiation therapy. Whole pelvic irradiation was administered with 10-MV X ray. Dose to the central cervix was 40-44 Gy in 20-22 fractions, following by pelvic wall boost 6-14 Gy in three to seven fractions with central shielding. 60Co sources were used for HDR-IC, and 7.2 Gy was given to Point A for three applications, 1-2 weeks apart. Duration of follow-up was 5-7.8 years. RESULTS: Twenty-eight patients (16%) developed central-regional recurrences. Overall 5-year actuarial pelvic control rate was 83%. By stage, 5-year actuarial pelvic control rates were 94%, 87%, and 72% for Stages IB + IIA, IIB + IIIA, and IIIB + IVA, respectively. Thirty-one patients (18%) developed distant metastasis. Overall 5-year actuarial survival rate was 58%. By stage, 5-year actuarial survival rates were 79%, 59%, and 41% for Stages IB + IIA, IIB + IIIA, and IIIB + IVA, respectively. Sixty-six (38%) and 19 patients (11%) developed rectal and bladder complications, respectively. For rectal complication, the overall actuarial rate was 38% at 5 years. By grade, 5-year actuarial rectal complication rates were 24%, 15%, 4%, and 3% for Grades 1-4, respectively. Overall prevalence of rectal complications was 37% and 14% at 2 and 5 years, respectively. Prevalence of low-grade rectal complication (Grades 1 and 2) was dominant at 2 years (30%), but declined to 8% at 5 years. Prevalence of high-grade, severe rectal complication (Grades 3 and 4) remained steady at 2 and 5 years (7% and 6%, respectively). Five-year actuarial bladder complication was 9%. Five-year prevalence of bladder complication was 2%. CONCLUSION: Using a three-fraction scheme, survival rate appeared comparable with the existing results of the low-dose-rate technique. The incidence of rectal complication with this scheme remained relatively high. The increased part of rectal complication was predominantly low grade. This result suggested that therapeutic gain with this scheme may not be good enough to circumvent its biologic disadvantage. Numbers of fractions >3 must be considered in future trials.

Unusual short rib-polydactyly syndrome.

We present a case of lethal short rib-polydactyly syndrome (SRPS) that cannot be categorized into the existing classification. A nosologic discussion is presented. To our knowledge, situs inversus totalis, as in our case, has not been described before in any SRPS.

Primary osteosarcoma of the uterus with peritoneal osteosarcomatosis: CT features.

A 67-year-old woman presented with lower abdominal pain for 1 month. Pelvic ultrasound revealed a calcified uterine mass and ascites. CT showed a heavily calcified uterine tumour, with ascites and disseminated calcified nodules in the peritoneum. Microscopic and immunohistochemical studies demonstrated features typical of osteosarcoma without any epithelial differentiation. Although rare, uterine osteosarcoma with associated peritoneal osteosarcomatosis should be included in the differential diagnosis of an elderly woman with a calcified uterine mass and disseminated peritoneal calcifications.

The role of radical surgery followed by adjuvant therapy for high-risk early-stage cervical carcinoma patients with pelvic lymph node metastasis.

OBJECTIVES: To identify a subgroup of high-risk node-positive patients in early-stage cervical cancers and to determine the role of radical hysterectomy followed by adjuvant therapy to these patients. STUDY DESIGN: We conducted a retrospective review of 482 surgically-treated patients of clinical stage Ib and IIa cervical carcinoma from July 1986 to December 1994 at Kaohsiung Chang Gung Memorial Hospital. Of these, 96 patients had pelvic lymph node metastases. Clinicopathological variables, including the level of pretreatment squamous cell carcinoma antigen (SCC-Ag), DNA flow cytometry analysis, and the use of different adjuvant therapies were studied. RESULTS: Disease-free survival was significantly worse among patients with S-phase fraction greater than 20% and pretreatment SCC-Ag level above 5 ng/ml. Utilizing these significant variables, we identified two distinct risk groups. Those patients without any of the risk variables were categorized as the low-risk group. Those patients with either one or both risk variables were categorized as the high-risk group. Five-year disease-free survival rates were 74% in the low-risk group and 43% in the high-risk group, (P=0.034). Disease recurred in 30.2% of the low-risk patients and 45. 3% of the high-risk patients. No survival advantages were found by using different adjuvant therapies. CONCLUSIONS: Radical hysterectomy should not be attempted if either the pretreatment SCC-Ag level is above 5 ng/ml or S-phase fraction of the tumor greater than 20% due to its limited value despite applying aggressive postoperative adjuvant therapy.

Twin pregnancy with hydatidiform mole (46, XX) and a coexistent fetus (46, XY): report of a case.

Coexistent hydatidiform mole (46, XX) and live fetus (46, XY) in the second trimester is a rare phenomenon. In this case, the clinical manifestations presented as pregnancy-induced hypertension, including hypertension, proteinuria and oliguria. Ultrasonic examination found an enlarged placenta with a typical honeycomb picture, placenta previa and a normal developing fetus. The patient underwent an emergency cesarean section at 23 weeks' gestation on a preliminary diagnosis of acute chorioamnionitis. A 700 g immature male baby was delivered with Apgar scores of 3 at one minute, and 7 at five minutes. The placenta was composed of two parts: one was a molar pregnancy and the other was a normal placenta, both were separated by the membrane. The membrane consisted of one chorion and two amnions. Postmolar persistence of human chorionic gonadotropin was found one month after termination of this pregnancy. Chemotherapy with a single agent (methotrexate) was given. The patient is doing well and has no evidence of recurrence after one year of follow-up.

Successful term pregnancy after selective embolization of a large postmolar uterine arteriovenous malformation.

Uterine arteriovenous malformations (AVM) are very uncommon disorders. Successful conservative treatment with subsequently conceived is rarely reported. We describe a 31-year-old woman with a complex and large postmolar AVM; she was successfully treated with transarterial selective embolization for a long history of repeated excessive vaginal bleeding and anemia. She resumed normal menstrual periods soon after treatment, and she subsequently conceived about 2 years later. A healthy male baby was delivered at 39 weeks of gestation via vaginal route. Selective embolization of a complex and large uterine AVM seems to be feasible for the treatment of uterine bleeding and preservation of reproductive capability.

Extrauterine müllerian adenosarcoma associated with endometriosis and rectal villotubular adenoma: report of a case and review of the literature.

Extrauterine mullerian adenosarcoma is rare and is thought to arise from endometriotic deposits or pluripotent mesothelial and mesenchymal cells of the pelvic cavity. Concomitant colon-rectal neoplasm was reported but the relationship between extrauterine adenosarcoma and colon tumor was not studied. We describe an extrauterine adenosarcoma with a concomitant rectal tubulovillous adenoma. The patient had a long-term history of endometriosis and unopposed estrogen therapy. Immunohistochemical study was performed to investigate the origin and nature of the adenosarcoma. Immunostaining provided the evidence to distinguish between rectal tumor and adenosarcoma. Extrauterine adenosarcoma may arise from endometriosis, and hormone replacement therapy may have some role in the malignant transformation process. Adenosarcoma should be considered in the differential diagnosis of a new pelvic tumor in a patient with a history of endometriosis.

[The amniotic band syndrome--report of two cases].

The amniotic band syndrome (ABS) includes intrauterine amputations, syndactyly, fetal disruption, fetal compression deformities and constriction rings associated with disruption of the amniotic membrane. The defects caused by ABS varied from simple digital band constrictions, limb defects to major visceral and craniofacial defects; fetal death may also occur. Because the ABS is a sporadic disorder that may mimic recurrent disorders, such as achondroplasia, anencephaly, Apert's syndrome, etc, it is very important to do appropriate genetic counseling and accurate diagnosis for every infant born with multiple birth defects. We report two severely damaged cases with typical features. This article also reviews the clinical features of ABS, its etiology, pathogenesis, and the status of prenatal and neonatal diagnosis are also discussed.

Vulvar Paget's disease and sweat gland carcinoma--report of a case and review of the literature.

A report of a 79-year-old woman with vulvar Paget's disease and underlying sweat gland carcinoma is given. Itching and oozing are the major symptoms. The clinical manifestations are diffuse erythematous, thickened and irregular scaling vulvar skin lesions that are similar to eczematous change. The Paget's cells appear large and round with abundant cytoplasm stained faintly with hematoxylin and eosin in the acanthotic epidermis. Wide local excision and reconstruction with myocutaneous gracilis flaps were carried out. No local recurrence was found after 1 year of follow-up. Skinning vulvectomy should be excluded as an option for treatment, as Paget's cells or underlying malignancy may exist in the adnexal structures of the skin which may be located in the subcutaneous tissue.

Successful pregnancy in a chronic hemodialytic woman--a case report.

Pregnancy in uremic patient is extremely rare. Successful outcome with live birth is achieved after the use of hemodialysis during the course of pregnancy but still remains distinctly uncommon. Good experiences in detection, prevention and management of maternal and fetal complications are limited. Under the care of multidisciplinary team including obstetrician, nephrologist, neonatologist and hemodialysis staff, a 27-year-old uremic woman on chronic hemodialysis for 3 years gave birth to a viable baby is reported.

Sebaceous carcinoma arising in a benign dermoid cyst of the ovary.

Sebaceous carcinoma in a ovarian dermoid cyst is a rare entity. The present patient has survived 54 months and has no evidence of recurrence after total abdominal hysterectomy, bilateral salpingo-oophorectomy and adjuvant chemotherapy with cisplatin, vinblastine, and bleomycin.

[Squamous cell carcinoma originating from ovarian dermoid cyst--report of three cases].

We report three cases of squamous cell carcinoma originating from ovarian dermoid cysts. All patients were postmenopausal with the chief complaints of lower abdominal pain and palpable masses found by themselves. Two of them had diabetes mellitus. The tumor sizes were all more than 10 cm. The diagnoses were made by histological examination of tissues removed at surgery. Two cases were categorized into the FIGO stage IIIc and one in stage Ia. Sonographic findings were characterized by a large adnexal mass with mixed components. An elevated serum squamous cell carcinoma antigen was found in the two cases of advanced stage and one of them also had an elevated serum CA-125 level. All reported cases were unilaterally involved without ascites at laparotomy, while omental lymph nodes metastases were noted in the two cases of advanced stage. One of the patients in the advanced stage died six months after surgery and radiation therapy due to recurrence. The other patient in the advanced stage refused further treatment even though recurrence was found five months after surgery and chemotherapy. There was no evidence of recurrence in the early stage case during the two years of follow-up.

Abdominal pregnancy--report of two cases and review of literature.

Ectopic pregnancy is one of the major complications of pregnancy. The abdominal pregnancy is a comparatively rare type of ectopic gestation with a high fetal and maternal morbidity and mortality. Although abdominal pregnancy had been well documented, it still remains a serious dilemma for most clinicians in the contemporary obstetric practice because of the difficulties in early diagnosis and proper management. We reported two cases of early abdominal pregnancy with accurate preoperative diagnosis followed by immediate surgical intervention and total removal of the placental tissue. The important concepts of management with this uncommon but ominous condition are discussed, including the predisposing risk factors, clinical features, diagnostic difficulties, appropriate surgery and management of the placenta.

[The clinical history of midtrimester low placentation].

The finding of low implantation of placenta during midtrimester is not uncommon. It does not constitute an immediate obstetric emergency, but rather demanding serial and thorough follow-up. Previous uterine trauma and scarring caused by Caesarean section is a significant predisposing factor, while the roles of maternal age, gravidity, parity, sex of newborn are controversial. Placenta previa patients have a tendency to develop antepartum hemorrhage and preterm labor. Neither IUGR nor congenital malformations are associated abnormalities in our study. The rate of cesarean section in patients with placenta previa has increased, but the risk of perinatal morbidity has not increased. "Migration" means the dynamic relationship between the placenta and internal O.S., which occurred in 79.6% cases overall, especially in the subgroup of low-lying and marginal placenta previa. The "migration" does not protect patients from operation, nonetheless, the defined "placenta previas" are not all destined to cesarean section. Ultrasonography is a helpful diagnostic tool, via abdominal or vaginal route, and is a practical guide of expectant management.

The McKusick-Kaufman hydrometrocolpos-polydactyly syndrome--a case report.

Hydrometrocolpos is a rare congenital anomaly and serious life threatening condition in the newborn infant due to its long-term compression sequelae and associated congenital anomalies. Prenatal diagnosis of hydrometrocolpos by sonogram allows appropriate management during the prenatal and neonatal period. The combination of hydrometrocolpos and polydactyly is the cardinal hallmark feature of McKusick-Kaufman Syndrome. We present a case of congenital hydrometrocolpos due to vaginal atresia combined with polydactyly of both feet, mild atrial septum defect, bilateral hydronephrosis, fetal ascites and polyhydramnios. Pathogenesis and treatment of hydrometrocolpos and its associated congenital anomalies are discussed.

Prediction of disease persistence after conization for microinvasive cervical carcinoma and cervical intraepithelial neoplasia grade 3.

We attempted to determine the significant variables and to predict the probability of disease persistence after conization for microinvasive cervical carcinoma and cervical intraepithelial neoplasia grade 3 (CIN3). We analyzed 133 patients from 2001 to 2002 who had a subsequent hysterectomy after conization. The histological findings of the cone specimens, together with the clinical parameters, were correlated with the presence of residual dysplasia in the hysterectomy specimen. The probability of having residual dysplasia was calculated based on the function of the significant variables obtained by logistic regression analysis. Of the 133 patients, 42 (31.6%) had residual disease in their hysterectomy specimens. Using multivariate analysis only for the postmenopausal state, positive endocervical curettage, positive margin, and microinvasive carcinoma were predictive of residual dysplasia. The probabilities of having residual dysplasia were about 0.99, 0.84, 0.4, 0.07, and 0.01 in patients with a presence of all four, any three, any two, any one, and no risk factors, respectively. The best cutoff probability determined by the receiver operating characteristic curve was 0.32, yielding a sensitivity of 81% and a specificity of 88%. Based on these results, patients with the presence of any two or more of the risk factors mentioned above should be considered as a high-risk group for having disease persistence after conization for the treatment of CIN3 and microinvasive carcinoma.

Early-onset sigmoid colon perforation during concurrent chemoradiation in a patient with cervical cancer.

Radiation-induced colon perforation is a rare adverse effect caused by vascular and connective tissue injury to the rectosigmoid colon. It usually occurs a few months to years after radiotherapy for gynecological cancer. Herein, we present a patient who developed sigmoid colon perforation during concurrent chemoradiotherapy for cervical cancer. The patient was a 64-year-old clinical stage IIB woman who received concurrent chemoradiotherapy as a standard treatment. The chemotherapeutic protocol was cisplatin 50 mg/m(2) and 5-fluorouracil 4000 mg, starting together with radiotherapy. After the completion of external beam radiation for 4500 cGy, the patient developed sigmoid colon perforation presenting with fecal peritoneum and sepsis. An emergency end ileostomy with resection of entire sigmoid colon was performed and the patient was discharged 3 months later in good condition. Clinicians must be highly suspicious of serious bowel perforation, even if the full dose of radiation has not been completed. Whether or not the chemotherapy was the trigger factor is in need of further clarification.

Survival advantages and complications of adjuvant therapy in early-stage cervical cancer with pelvic node metastasis.

BACKGROUND: Patients with early-stage cervical cancer who have pelvic node metastasis usually need adjuvant therapy after surgery for improvement of the length of survival. We attempted to determine the survival advantages and complications associated with different adjuvant therapeutic modalities. MATERIALS AND METHODS: Eighty-seven patients with clinical stage Ib and IIa cervical cancer were treated with radical hysterectomy from July 1986 through December 1994 were reviewed retrospectively. All had had lymph node metastasis. The patients were divided into three groups according to the different adjuvant therapeutic approaches utilized: radiation (group I, n = 43), chemotherapy (group II, n = 23), and chemoirradiation (group III, n = 21). RESULTS: There was no significant difference among these three groups in the 5-year relapse-free survival rate (group I: 63%, group II: 62%, group III: 51%, p = 0.785). The recurrence rates among these three groups were found to be similar (group I: 32.6%, group II: 39.1%, group III: 47.6%, p = 0.331). However, most of the recurrence in patients who had received pelvic radiation was at a distant site (group I: 79%, group III: 80%) as compared to the patients who had received chemotherapy only (group II: 33%), and the differences were significant (p = 0.020). The rates of complications, such as severe leukopenia, lymphedema with cellulitis, proctosigmoiditis and ileus, were found to be lower in the chemotherapeutic group. CONCLUSION: Although we failed to demonstrate the survival advantages of different adjuvant therapeutic approaches, we still favor chemotherapy as an adjuvant basis because it is the least toxic of the regimens.

Effect of acetic acid on telomerase activity in cervical intraepithelial neoplasia.

OBJECTIVE: To evaluate whether the telomerase activity in CIN lesions can be affected by a chemical solution of acetic acid, which is required to apply to the cervix prior to colposcopy-directed biopsy. MATERIALS AND METHODS: Thirty-five patients with histologically confirmed high-grade squamous intraepithelial lesions of the cervix entered the study. Two specimens were collected from each patient, one before and one after the cervix was swabbed with 5% acetic acid. The standard telomeric repeat assay protocol (TRAP) was used to examine telomerase activity in these fresh frozen tissue samples. Normal cervical tissues from 10 control individuals were also examined for the presence of telomerase activity. A total of 80 specimens was analyzed. RESULTS: Telomerase activity was detectable in 27 of 35 (77.1%) fresh tissue samples, 15 of 35 (42.9%) tissue samples swabbed with 5% acetic acid, and 0 of 10 (0%) normal cervical tissue samples, respectively. Twelve samples became telomerase negative after 5% acetic acid applied. Among the 15 telomerase-positive tissue samples swabbed with 5% acetic acid, 12 had relative weak telomerase activity compared to corresponding fresh tissue samples, the other 3 remained the same. Therefore, it is concluded that telomerase activity was affected by 5% acetic acid in 24 of 27 (88.9%) samples. Telomerase activity in HeLa cell line was also inhibited by 5% acetic acid. CONCLUSION: We reported a relative high percentage of telomerase expression in high-grade CIN lesions when compared with previous reports. If detection of telomerase activity is to become a tool for diagnosis and prognosis of cervical neoplasias, applying acetic acid prior to colposcopy-directed biopsy that is submitted for telomerase assay should be avoided in order to increase the detection rate.