A very rare case of vaginal angiokeratoma.

Angiokeratomas are benign, vascular lesions that are very rarely identified in the vagina. A patient originally presented with endometrial cancer in 1993 and was cured following surgery and adjuvant radiotherapy. However, in 2007, she developed multiple, erythematous, vaginal nodules that were eventually diagnosed as angiokeratoma of the vagina. The diagnosis of vaginal angiokeratoma may not be initially suspected. Therefore, physicians should perform a histologic examination to verify the condition and accordingly, provide relevant clinical management.

Clostridial abdominal gas gangrene masquerading as a bowel perforation in an advanced-stage ovarian cancer patient.

The coexistence of clostridial gas gangrene and a gynecologic malignancy is extremely rare, with very few cases involving ovarian cancer. A patient originally presented to our gynecologic oncology service with stage IV ovarian cancer; she underwent a diagnostic laparoscopy and neoadjuvant chemotherapy. On postoperative day 6, the patient developed severe abdominal pain, nausea, and emesis, suggestive of a bowel perforation. Further evaluation confirmed that her symptoms were attributed to Clostridium perfringens-related gas gangrene. Despite immediate surgical intervention, the patient succumbed to her disease. Clostridial gas gangrene is associated with an extremely high mortality rate. Therefore, accurate detection and prompt management are indispensable to ensuring a favorable patient outcome.

Bevacizumab, paclitaxel and carboplatin for advanced ovarian cancer: low risk of gastrointestinal and cardiovascular toxicity.

The purpose of this preliminary study was to retrospectively assess the incidence of bowel perforation and hypertension in two separate advanced ovarian cancer patient populations following first-line therapy, comprising paclitaxel, carboplatin and bevacizumab. The first 20 patients were treated with six cycles of paclitaxel (175 mg/m2), carboplatin (AUC of 5 i.v.), and bevacizumab (15 mg/kg of body weight); q21 days per an independent protocol. The subsequent patients (n = 12) were administered weekly paclitaxel (80 mg/m2), carboplatin (AUC of 5 i.v.) every four weeks, and bevacizumab (10 mg/kg of body weight) every two weeks for six cycles according to a separate, independent protocol. Bevacizumab was not added to either chemotherapy regimen until cycle 2. In both groups patients who achieved a complete response, partial response or stable disease at the conclusion of induction therapy received bevacizumab (10 mg/kg) and paclitaxel (135 mg/m2) q21 days as maintenance therapy. A total of 170 cycles (median = 6; range 3-6) of primary induction chemotherapy, 140 of which contained bevacizumab, were administered. Moreover, 206 cycles (median = 9; range 1-12) of maintenance chemotherapy have been delivered to 28 patients thus far. There was no incidence of GI perforation and only two patients demonstrated clinically significant hypertension. Previous studies involving bevacizumab have raised concerns regarding bowel perforations and hypertension. However, we did not encounter difficulties with either of these complications. While we recognize that the risk for bowel perforation remains in the 5-11% range, the study's preliminary results suggest that first-line treatment of advanced stage ovarian carcinoma with bevacizumab can be safely administered.

The utility and cost of routine follow-up procedures in the surveillance of ovarian and primary peritoneal carcinoma: a 16-year institutional review.

BACKGROUND: The purpose of this study was to evaluate the number of ovarian cancer and primary peritoneal cancer (PPC) progressive disease cases identified via routine follow-up procedures and the corresponding cost throughout a 16-year period at a single medical institution. METHODS: Previously undiagnosed epithelial ovarian (n=241), PPC (n=23), and concurrent ovarian and uterine (n=24) cancer patients were treated and then followed via CA-125, imaging (e.g., CT scan, chest X-ray), physical examination and vaginal cytology. RESULTS: In the group of 287 patients, there were 151 cases of disease progression. Serial imaging detected the highest number of progressive disease cases (66 initial and 45 confirmatory diagnoses), but the cost was rather high ($13,454 per patient recurrence), whereas CA-125 testing (74 initial and 20 corroborative diagnoses) was the least expensive ($3,924) per recurrent diagnosis. The total cost of surveillance during the 16-year period was nearly $2,400,000. CONCLUSION: Ultimately, serial imaging and the CA-125 assay detected the highest number of ovarian cancer and PCC progressive disease cases in comparison to physical examination and vaginal cytology, but nevertheless, all of the procedures were conducted at a considerable financial expense.

Cerebral nocardia masquerading as metastatic CNS disease in an endometrial cancer patient.

Nocardia is a bacterial infection primarily originating from organic rich soil, endemic to several international geographic locations. We present the case of a 61-year-old woman previously treated for endometrial carcinoma, who three years later developed metastatic pulmonary disease and received systemic chemotherapy. After five months, she developed a large right posterior lobe lesion, suspicious for metastatic CNS disease. However, following neurosurgical resection of the lesion and infectious disease consultation, a diagnosis of nocardia was made.

Marlex mesh mimicking an adnexal malignancy.

Hernia post-operative repair problems are infrequent and easily managed, but plug migration can be a more complicated event. Mesh plug migration is very uncommon and rarely presents as a suspected malignancy. We document a case involving a 79-year-old woman who exhibited a complex right-sided cystic mass that was presumed to be an adnexal malignancy. However, following surgery, the retroperitoneal mass was actually a PerFix mesh plug that migrated from an initial hernia surgery.

Tuberculosis mimicking cervical carcinoma--case report.

Tuberculosis is a chronic bacterial infection that primarily results in pulmonary disease. Although there are several reported cases of extra-pulmonary tuberculosis, very few reports have described this disease in the female genital tract. We present a case involving a 67-year-old woman who presented with vaginal discharge, abdominal discomfort, and a pelvic mass in 2006. Clinically, cervical carcinoma was suspected, but pathologic diagnosis eventually revealed tuberculosis of the cervix. Tuberculosis is associated with a significant inflammatory reaction, which may mimic a gynecologic malignancy on exam or with diagnostic imaging. Despite the rare incidence, tuberculosis of the cervix should be considered in the differential diagnosis when cervical carcinoma is initially suspected.

A phase II study of outpatient first-line paclitaxel, carboplatin, and bevacizumab for advanced-stage epithelial ovarian, peritoneal, and fallopian tube cancer.

The purpose of this study was to assess the response rate and toxicity of paclitaxel, carboplatin, and bevacizumab (PCB) primary induction therapy for the treatment of advanced-stage ovarian carcinoma. Twenty patients were treated with paclitaxel (175 mg/m(2)), carboplatin (AUC of 5 IV), and bevacizumab (15 mg/kg) of body weight; q21 days for six cycles. Bevacizumab was administered at cycles two through six. Patients received 116 cycles of PCB chemotherapy (median = 6, range 2-6) and were evaluable for toxicity assessment. Grade 3 and 4 neutropenia developed in 23.3% and 25% of cycles, with no incidence of grades 3/4 thrombocytopenia or anemia. Prior to cycle six, one patient was removed from the study due to grade 3 neuropathy and another patient was excluded due to clinical deterioration. There was no incidence of gastrointestinal perforations, and only two patients demonstrated grade 3 hypertension (HTN). No grade 4 HTN was observed. Eighteen patients were evaluated for response following induction therapy. Six demonstrated a complete response (30%) and ten exhibited a partial response (50%), resulting in a total response rate of 80%. One patient exhibited stable disease (5%), and one demonstrated disease progression (5%). The lack of bowel perforations and wound complications should mitigate some concerns regarding these side effects. This study suggests that first-line treatment with PCB can be safely administered to previously untreated advanced-stage ovarian carcinoma patients. The favorable toxicity results and reasonable response rate warrant additional study in a larger patient population.

Surgery alone or surgery with a combination radiation or chemoradiation for management of patients with bulky-stage IB2 cervical carcinoma.

The management of stage IB2 cervical carcinoma remains controversial. This retrospective review evaluates 47 IB2 cervical carcinoma patients treated with surgery alone (S), surgery plus postoperative radiotherapy (SR), or surgery plus postoperative chemoradiation (SRC). Median progression-free interval (PFI) was 70.3 months for the SR group (n= 21), 73.3 months for the SRC group (n= 15), and 33.5 months for the S group (n= 11). The survival rate was 76% for the SR group, 87% for the SRC group, and 55% for the S group. Overall 5-year survival rate for the three groups was 75%. Median follow-up for the patient population was 61.3 months. The number of the patient and the nonrandomized nature of this study preclude any definitive conclusions, but interestingly, the SRC and SR groups exhibited a substantially better PFI and overall survival compared to the S group. Selection bias does not appear to be a factor since patients in SR or SRC group were at greater risk for recurrence (eg, higher incidence of deep stromal invasion, parametrial involvement) than patients in the S group; yet, they still experienced superior PFI and overall survival. Further studies comparing postoperative irradiation and chemoradiation with these patients in a randomized phase 3 trial may be warranted.

Spontaneous bacterial peritonitis following treatment for cervical carcinoma.

Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection usually associated with ascites and cirrhosis or is a complication of peritoneal dialysis. There are very few case reports of cancer patients who developed this disease. Furthermore, there have been no published case reports of successfully treated gynecological cancer patients who later developed SBP. We present a case involving a 41-year-old woman who was treated for cervical carcinoma in 1992. She underwent radical surgery and adjuvant chemoradiation therapy. Two years later, the patient presented with streptococcal group B cellulitis associated with left leg lymphedema. She recovered following antibiotic treatment but had recurrent episodes of streptococcal cellulitis in her leg over the past 10 years. In 2003, the patient was admitted to the hospital because of sepsis, acute renal failure, and SBP. She was treated and recovered following treatment. SBP is usually associated with cirrhosis. Although SBP is rarely seen in successfully treated gynecological cancer patients, oncologists should be aware of this clinical entity. Timely treatment is essential to maximize chances of survival.

Late cognitive and radiographic changes related to radiotherapy: initial prospective findings.

BACKGROUND: Assumptions about the damaging effects of radiotherapy (XRT) are based on studies in which total dose, dose fraction, treatment volume, degree of malignancy, chemotherapy, tumor recurrence, and neurologic comorbidity interact with XRT effects. This is a prospective, long-term study of XRT effects in adults, in which total dose and dose fraction were constrained and data related to tumor recurrence and neurologic comorbidity (e.g., hypertension) were excluded. METHODS: The effects of XRT on the cognitive and radiographic outcomes of 26 patients with low-grade, supratentorial, brain tumors yearly from baseline (6 weeks after surgery and immediately before XRT) and yearly to 6 years were examined. Radiographic findings were examined regionally. RESULTS: Selective cognitive declines (in visual memory) emerged only at 5 years, whereas ratings of clinical MRI (T2 images) showed mild accumulation of hyperintensities with post-treatment onset from 6 months to 3 years, with no further progression. White matter atrophy and total hyperintensities demonstrated this effect, with subcortical and deep white matter, corpus callosum, cerebellar structures, and pons accounting for these changes over time. About half of the patients demonstrated cognitive decline and treatment-related hyperintensities. CONCLUSIONS: There was no evidence of a general cognitive decline or progression of white matter changes after 3 years. Results argue for limited damage from XRT at this frequently used dose and volume in the absence of other clinical risk factors.

Neuropsychological treatment of dyslexia in the classroom setting.

The purpose of this study was to validate Bakker's (1990, 1992) clinical neuropsychological balance model of dyslexia when implemented in a traditional general education classroom environment. The sample included 45 middle school, right-handed boys and girls (mean age = 12.78) with L-type dyslexia (excessively fast readers who make substantive reading errors), P-type dyslexia (displaying accurate but slow and laborious reading), and M-type dyslexia (readers who commit a combination of L-type and P-type dyslexia errors). The experimental groups (L and P type dyslexia) were presented with hemisphere specific stimulation (HSS) and hemispheric alluding stimuli (HAS). HSS involves the presentation of words into the right visual field (RVF) or the left visual field (LVF) or through tactile exercises with the right or left hand. HAS is achieved by constructing semantically and phonetically challenging letters and words. The children with M-type dyslexia served as a control group and received traditional decoding and comprehension exercises. The readers were exposed to a specific treatment model for 16 weeks, depending on their reading accuracy and comprehension. Statistical analyses indicated that, although there were no significant changes in word recognition for the dyslexia subtypes, the readers with L-type, P-type, and M-type dyslexia exhibited significant improvement in reading accuracy and comprehension as assessed by results from pretest to posttest. These results suggest that Bakker's clinical neuropsychological intervention can be effectively applied to the general education setting as well.

Unconventional dentistry: Part III. Legal and regulatory issues.

This is the third in a series of 5 articles providing a contemporary overview and introduction to unconventional dentistry (UD) and its correlation to unconventional medicine (UM). UD presents issues of dental quackery, fraud and malpractice, and it also engenders professional concerns about public protection and professional risks. Case reports illustrate numerous issues. The reader is encouraged to evaluate the cases for problems related to malpractice, fraud, ethics, behaviours and professionalism. A discussion of ethical issues is beyond the scope of this paper.

Unconventional dentistry: Part II. Practitioners and patients.

This is the second in a series of five articles providing a contemporary overview and introduction to unconventional dentistry (UD) and its correlation with unconventional medicine (UM). Dentists may provide unconventional services and use or prescribe unconventional products because of personal beliefs, boredom with conventional practice, lack of understanding of the scientific process or financial motivation. To promote these UD practices, unrecognized credentials and self-proclaimed specialties are advertised. Characteristics of users of unconventional practices are varied; however, UD users are more often female and highly educated. UD practitioners and users generally appear to be analogous to UM practitioners and users. Some UD treatments are more invasive or more costly than conventional dentistry.

Unconventional dentistry: Part I. Introduction.

This is the first in a series of five articles providing a contemporary overview and introduction to unconventional (alternative) dentistry (UD) and correlation with unconventional (alternative) medicine (UM). UD is analogous to and conceptually inseparable from UM. Dentists should learn about UD and UM and be aware of evidence on the safety and effectiveness of treatments and procedures. While being skeptical of promotions, dentists should be able to accept and encompass science-based advances and reject unproven and disproven methods. Incorporating selected unconventional methods with conventional dentistry in selected patients for specific purposes may be useful to both patients and dentists. Improved education in critical thinking, research, science, medicine, behaviour, communication and patient management is needed.