Severe delayed postpartum hemorrhage due to a neglected uterine diverticulum: a case report.

BACKGROUND: Symptomatic uterine diverticula are rare and, to our knowledge, have never been reported as a cause of postpartum hemorrhage. CASE: A 35-year-old woman presented with severe vaginal bleeding on the 47th day after a cesarean section. She had received endometrial curettage due to postpartum hemorrhage a few days earlier in another local hospital. Transvaginal ultrasound revealed a thickened heteroechoic endometrium and an isolated isthmic heteroechoic cystic lesion. Repeat endometriaI curettage was performed initially. However, recurrent vaginal bleeding and hypovolemic shock occurred 2 days later. Active bleeding from a debris-full diverticulum in the lateral wall of the uterine isthmus was found during an emergent hysterotomy. The myometrium was sutured to obliterate the diverticulum. The follow-up course was uneventful. CONCLUSION: Uterine diverticula may present as isolated isthmic heteroechoic cystic lesions and may be overlooked as a cause of severe delayed postpartum hemorrhage.

Borderline mucinous ovarian tumor presenting as pseudo-Meigs' syndrome.

Borderline ovarian tumor with the initial presentation of pseudo-Meigs' syndrome is rare. A 52-year-old postmenopausal woman presented with a large ovarian tumor, ascites, and right hydrothorax. We found elevated serum carcinoembryonic antigens (44.4 ng/mL), carbohydrate antigen (CA)-125 (269.8 U/mL), and CA-199 (7942 U/mL). The frozen section pathology revealed a mucinous borderline ovarian tumor, and a staging operation was performed. Final pathologic examination confirmed the diagnosis of intestinal type ovarian mucinous borderline tumor with non-invasive cul-de-sac implants. Her pleural effusion and ascites resolved after surgery, and she remained tumor-free after 3 years' follow up. Physicians should be cautious for the rare possibility of pseudo-Meigs' syndrome in patients with pelvic tumors having the features of advanced ovarian cancer.

Ultrasonographic differentiation between Kikuchi's disease and lymphoma in patients with cervical lymphadenopathy.

PURPOSE: Kikuchi's disease, or histiocytic necrotizing lymphadenitis, is a self-limited necrotizing lymphadenitis. Clinically, it resembles lymphoma. We want to compare the sonographic features between Kikuchi's disease and lymphoma in patients with cervical lymphadenopathy. MATERIALS AND METHODS: The study protocol was approved by the institutional review board. Two hundred and twenty six cervical lymph nodes (137 nodes from 21 Kikuchi's disease patients and 89 nodes from 20 malignant lymphoma patients) were examined. The demographic and ultrasonographic characteristics of lymph nodes were collected and analyzed. RESULTS: The Kikuchi's disease patients (mean age, 24.2 years; range, 8-57 years) were younger than those with lymphoma (mean age, 54 years; range, 13-81 years). There was no difference in laterality of nodes (p=0.19). The nodal distribution demonstrated most enlarged neck lymph nodes located at level II, III and V. The ranges of short-axis and long-axis length were 6.5±2.3mm (mean±SD) versus 13.4±5.1mm and 13.4±5.0mm versus 21.2±9.2mm for Kikuchi's disease versus lymphoma (p<0.01), respectively. The S/R ratio of Kikuchi's disease nodes was 0.5±0.2 compared to 0.7±0.2 in lymphoma nodes (p<0.01). Eighty-seven of 137 nodes (63.5%) of Kikuchi's disease, and eight of 89 nodes (9%) of malignant lymphoma had signs of cortical widening (p<0.01). Seventy-six nodes (55.5%) of Kikuchi's disease and twenty-eight nodes (31.5%) of malignant lymphoma were matted (p<0.01). Forty-five of 89 nodes among lymphoma and twenty-four among 137 of Kikuchi's disease had features of micronodular reticular echotexture (p<0.01). All nodes exhibited hypoechogenicity except one lymphomatous node demonstrated isoechogenicity, and there was no difference in sharpness of border and presence of echogenic hilum between the two diseases (p>0.05). CONCLUSION: Analysis of basic ultrasonographic characteristics (size, shape, rims, matting and echotexture) helps differentiate cervical lymph nodes in patients with Kikuchi's disease and lymphoma. Cervical lymphadenopathies in patients with Kikuchi's disease have smaller size, less round, less micronodular reticular echotexture, and more signs of matting and cortical widening than those with lymphoma examined under ultrasound.

Norcantharidin modulates development of dendritic cells and prolongs skin allograft survival.

BACKGROUND: To examine the effects of norcantharidin (NCTD) on development of human myeloid dendritic cells (DCs) in vitro and in skin allograft transplantation in vivo. METHODS: Human CD14(+) monocytes were isolated and triggered differentiation and maturation toward myeloid DCs with and without NCTD. The cell morphology, viability, cell death, expression of surface markers and co-stimulatory molecules, allostimulatory activity, and cytokine production were examined for characterization of DCs. The rejection of mice skin allograft model was used to translate the in vitro effect of cantharidin (CTD) and NCTD on DCs. RESULTS: DCs developed in the presence of NCTD showed decreased viability, cell death with necrosis, and lower expression of CD1a and CD83. DCs triggered in the presence of NCTD possessed a greater allostimulatory activity in naive CD4(+)CD45RA(+) T cells. NCTD modulated DCs through calcineurin phosphatase but not through mammalian target of rapamycin or downstream molecule p70S6 kinase. In vivo, NCTD caused accumulation and co-localization of antigen-presenting cells and regulatory T cells in the interfollicular area of the recipients' spleens. CTD and NCTD prolonged skin allograft survival along with less severe histopathological inflammatory reactions. CTD, but not NCTD, treatment caused elevation of serum alanine aminotransferase and evident mortality of the recipients. CONCLUSION: NCTD modulated the differentiation and maturation of human myeloid DCs and caused deviation of standard DC differentiation toward a tolerogenic phenotype through calcineurin phosphatase inhibition. In vivo, both drugs effectively prolonged skin allograft survival. NCTD was less toxic than CTD, and thus, has potential for development as an immunosuppressant for transplant rejection.

Should helical tomotherapy replace brachytherapy for cervical cancer? Case report.

BACKGROUND: Stereotactic body radiation therapy (SBRT) administered via a helical tomotherapy (HT) system is an effective modality for treating lung cancer and metastatic liver tumors. Whether SBRT delivered via HT is a feasible alternative to brachytherapy in treatment of locally advanced cervical cancer in patients with unusual anatomic configurations of the uterus has never been studied. CASE PRESENTATION: A 46-year-old woman presented with an 8-month history of abnormal vaginal bleeding. Biopsy revealed squamous cell carcinoma of the cervix. Magnetic resonance imaging (MRI) showed a cervical tumor with direct invasion of the right parametrium, bilateral hydronephrosis, and multiple uterine myomas. International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical cancer was diagnosed. Concurrent chemoradiation therapy (CCRT) followed by SBRT delivered via HT was administered instead of brachytherapy because of the presence of multiple uterine myomas with bleeding tendency. Total abdominal hysterectomy was performed after 6 weeks of treatment because of the presence of multiple uterine myomas. Neither pelvic MRI nor results of histopathologic examination at X-month follow-up showed evidence of tumor recurrence. Only grade 1 nausea and vomiting during treatment were noted. Lower gastrointestinal bleeding was noted at 14-month follow-up. No fistula formation and no evidence of haematological, gastrointestinal or genitourinary toxicities were noted on the most recent follow-up. CONCLUSIONS: CCRT followed by SBRT appears to be an effective and safe modality for treatment of cervical cancer. Larger-scale studies are warranted.