Adenomyosis and risk of preterm delivery.

OBJECTIVE: To evaluate the risk of preterm delivery in patients with adenomyosis. DESIGN: A 1:2 nested case-control study. SETTING: Tertiary-care institution. POPULATION: A base cohort population of 2138 pregnant women who attended routine prenatal check-up between July 1999 and June 2005. METHODS: From this base cohort population, gravid women with singleton pregnancy who delivered prior to the completion of 37 weeks of gestation were identified and formed the study group. Singleton gravid women who had term delivery and who matched with age, body mass index, smoking, and status of previous preterm delivery were recruited concurrently and served as control group. Preterm delivery cases were further divided into spontaneous preterm delivery and preterm premature rupture of membranes (PPROM) cases. MAIN OUTCOME MEASURES: Risk analysis of preterm delivery between gravid women with and without adenomyosis. RESULTS: One-hundred and four preterm delivery case subjects and 208 control subjects were assessed. Overall, gravid women with adenomyosis were associated with significantly increased risk of preterm delivery (adjusted odds ratio 1.96, 95% CI 1.23-4.47, P=0.022). For subgroup analysis, gravid women with adenomyosis had an adjusted 1.84-fold risk of spontaneous preterm delivery (95% CI 1.32-4.31, P=0.012) and an adjusted 1.98-fold risk of PPROM (95% CI 1.39-3.15, P=0.017). CONCLUSIONS: Gravid women with adenomyosis were associated with increased risk of both spontaneous preterm delivery and PPROM. A common pathophysiological pathway may exist in these two disorders. Further in-depth biochemical and molecular studies are necessary to explore this phenomenon.

Potential role of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma.

PURPOSE: Most comparisons between uterine leiomyoma and uterine leiomyosarcoma have been based on postoperative pathological or molecular analyses. Very few reports have investigated preoperative differentiation between uterine leiomyoma and uterine leiomyosarcoma. METHODS: Between January 1990 and December 2003, 42 consecutive patients with uterine leiomyosarcoma treated at index hospitals were analyzed. Meanwhile, 84 patients with uterine leiomyomas were used as controls. The diagnostic performance of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma using receiver operating characteristic (ROC) curves was evaluated. Data presentations were categorized into premenopausal and postmenopausal groups. Diagnostic efficiency was calculated as the sensitivity multiplied by the specificity. RESULTS: Values of preoperative serum CA125 were significantly higher in the uterine leiomyosarcoma group than those in the uterine leiomyoma group. There was significant overlapping of preoperative serum CA125 between the uterine leiomyoma group and early-stage uterine leiomyosarcoma. For both the premenopausal and postmenopausal group, there was a significant difference in the distribution of preoperative serum CA125 in early-stage and advanced-stage uterine leiomyosarcoma. The optimal cutoff values of serum CA125 for the premenopausal group and postmenopausal group was 162 U/mL and 75 U/mL, respectively. CONCLUSION: These findings demonstrated that preoperative serum CA125 had a potential role in the differential diagnosis between early-stage and advanced-stage uterine leiomyosarcoma. Further investigation with a larger sample size at adequate power is necessary to verify the current study.

Parametrial tumor spreading patterns in cervix cancer patients treated by radical hysterectomy.

OBJECTIVES: To evaluate tumor-spreading patterns in the parametrium. METHODS: We conducted a prospective clinical trial between January 1998 and December 2000 to define a new method for parametrium evaluation. The parametrium was divided into three areas, paracorpus, paracervix, and paravagina. A total of 284 consecutive patients with FIGO stage IB to IIA cervical cancer who had undergone radical hysterectomy were considered for the study. RESULTS: Of the 262 patients who were found eligible for evaluation, 135 had histopathologic analysis performed according to the new method and 127 with the traditional method. The detection of rate of parametrial invasion was 36 (26.7%) with the new and 13 (10.2%) with the traditional method (P=0.0014). The frequency of pelvic lymph node metastasis was 66.7% in patients who had tested positive for invasion of the paracorpus, 57.7% in those who had tested positive for invasion of the paracervix, and 71.4% in those who had tested positive for invasion of the paravagina. The frequency of pelvic lymph node metastasis in patients who had tested negative for invasion of the paracorpus, paracervix, or paravagina was 4.0%. Tumor cells tend to spread laterally and inferiorly in the parametrium. CONCLUSIONS: Using our classification of three parametrium areas for histologic examination can increase the detection rates of parametrial tumor invasion and help prevent failure of local treatment by allowing to implement appropriate adjuvant therapy.

Intraperitoneal cancer spread after laparoscopic cystectomy for mature teratoma with malignant transformation.

Laparoscopic surgery for ovarian dermoid cysts has been accepted. However, its potential limitations should be considered, including technique difficulty, intraoperative tumor spillage and malignant transformation. We report a case of ovarian dermoid cysts with malignant transformation that was initially treated using laparoscopic cystectomy, but was complicated by intraperitoneal tumor dissemination.

Both TPA and SCC-Ag levels are prognostic even in high-risk stage Ib-IIa cervical carcinoma as determined by a stratification analysis.

OBJECTIVE: To determine the prognostic values of tissue polypeptide antigen (TPA), squamous cell carcinoma antigen (SCC-Ag), and carcinoembryonic antigen (CEA) in the sera of cervical carcinoma patients, especially in those with a poor prognosis. METHODS: In this retrospective study, the preoperative serum SCC-Ag, TPA, and CEA were analyzed in 779 patients with cervical squamous cell carcinoma of stage Ib-IIa who received radical hysterectomy and pelvic lymph node dissection (RAH-PLND) between 1984 and 1994. RESULTS: Due to poor predictive value and poor correlation between serum CEA and clinico-pathological factors, CEA was abandoned in this study. Elevated TPA and SCC-Ag levels, pelvic lymph node metastasis (PLNM), lymphvascular space involvement (LVSI) and deep stromal invasion (DSI) were associated with poor survival time by univariate analysis. The correlation study showed that elevated serum TPA was significantly related to PLNM, LVSI, and DSI (p = 0.004, 0.008, and 0.021, respectively), and SCC-Ag was related to PLNM and bulky tumor size (p = 0.001 and 0.02, respectively). In the multivariate analysis, only PLNM and LVSI remained independently significant indicating poor survival. Further stratification studies by PLNM and LVSI showed that elevated TPA levels could even indicate higher recurrence rates in patients with PLNM (p = 0.045), as well as SCC-Ag in patients with LVSI (p = 0.038). CONCLUSIONS: The results suggest that both elevated TPA and SCC-Ag levels depicting poor prognosis in stage Ib-IIa cervical SCC, especially indicates a group of high-risk patients who may need more aggressive therapy.

Altered mRNA expression of sialyltransferase in squamous cell carcinomas of the cervix.

OBJECTIVE: Increased sialylation has been reported in various kinds of cancers, but to date, sialylation of cervical carcinoma has never been evaluated. This study of the changes in messenger ribonucleic acid (mRNA) expression of the four sialyltransferases (ST3Gal I, ST3Gal III, ST3Gal IV, and ST6Gal I) in a normal cervix and that with FIGO stage IB1 squamous cell carcinoma was undertaken to assess the extent of sialylation associated with establishment of the carcinoma. METHODS: Alterations in ST mRNA expression in FIGO IB1 cervical cancer (n = 30) and normal cervixes (n = 30) were examined by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: ST6Gal I expression was enhanced in squamous cell carcinoma of the cervix (P = 0.026, Mann-Whitney U test), but mRNA expression from the other three STs (ST3Gal I, ST3Gal III, and ST3Gal IV) was significantly down-expressed in squamous cell carcinoma of the cervix compared to the normal cervix (P = 0.003, P < 0.001, and P = 0.001, respectively). High ST6Gal I expression was associated with more invasive properties of cervical cancer, such as deep stromal invasion, lymph or vascular space involvement, and poor differentiation (P = 0.010, P < 0.001, P < 0.001, respectively). CONCLUSIONS: A combination of enhanced ST6Gal I mRNA expression and decreased mRNA expression from ST3Gal I, ST3Gal III, and ST3Gal IV might be important in cervical cancer. Future studies will investigate whether RT-PCR detection of the expression of these enzymes can be helpful for prognostic purposes.

Primary epithelial ovarian carcinoma in Taiwanese women.

PURPOSE OF INVESTIGATION: Primary epithelial ovarian carcinoma is common in industrial countries but rare in the Orient. In fact, it is still a rare disease in Taiwan. In this article, we report the general data of Taiwanese patients with primary epithelial ovarian carcinoma. METHODS: In this retrospective study we used univariate and multivariate analysis models to analyze the prognosis of patients with surgically confirmed primary epithelial ovarian carcinoma. One hundred and ninety-four patients from 1990 to 1996 were identified and enrolled in this study. RESULTS: The mean follow-up time was 44.7 months with an interval between 15.1 months and 105.9 months. Univariate analysis showed postmenopausal status, advanced stage, presence of lymph node metastasis, poor differentiation, and suboptimal surgery as risk factors for disease recurrence and subsequent deaths. Multivariate analysis demonstrated stage as the most important factor correlated with recurrent disease (risk ratio: 7.303 and 5.409, respectively), followed by optimal surgery (RR: 2.447), and cellular differentiation (RR: 1.677). CONCLUSIONS: Our data on the Taiwan population were consistent with other reports of different races. Early detection for primary epithelial ovarian cancer is of great importance because stage is still the most important predictor in disease-free survival and disease-related deaths. Application of the most reliable and acceptable methods of screening is our goal in the next century after weighing benefits over costs.

Excision of mature teratoma using culdotomy, with and without laparoscopy: a prospective randomised trial.

OBJECTIVE: To compare the results of removing mature teratoma with laparoscopy or without laparoscopy. DESIGN: A prospective, randomised trial. SETTING: Medical centre. PARTICIPANTS: Seventy-nine women with mature teratomas identified using results of ultrasound examinations and biochemical markers. INTERVENTION: Cystectomy with laparoscopic approach or without laparoscopic approach through a culdotomy. METHODS: Patients were randomly assigned to have their cysts removed via vaginal cystectomy without laparoscopy (n = 37, Group A) or laparoscopic cystectomy via culdotomy opening (n = 42, Group B). Inclusion criteria were history of vaginal delivery, no previous abdominal surgery, no history of pelvic inflammatory disease, no medical illness, and no presenting symptoms. Eight women randomised to Group A withdrew before surgery. The laparoscopically resected tumours were each put into a cellulose bag, and tumours without laparoscopic-assistance were removed directly via the vagina. RESULTS: Blood loss in Group A (88 +/- 37 ml) was significantly more than that in Group B (64 +/- 20 ml, P = 0.000). The post-operative recovery times were 20 and 17 hours, respectively (P = 0.030). The rates of successful surgery were 58.6 and 97.6%, respectively (P = 0.002). The spillage rates were 44.8% and 19.0%, respectively (P = 0.006). There were no significant differences in tumour size, patient age, and operative time between groups. CONCLUSION: Cystectomy without assistance of laparoscopy could be applied to manage mature teratoma of the ovary; however, because of the difficulty of this technique, we had high percentages of tumour spillage and more blood loss during operation and a high percentage of patients who required conversion to laparotomy compared with laparoscopic cystectomy. We favoured laparoscopically assisted cystectomy to manage mature teratoma.

Intraperitoneal cisplatin-based chemotherapy vs. intravenous cisplatin-based chemotherapy for stage III optimally cytoreduced epithelial ovarian cancer.

OBJECTIVE: To compare the survival between intraperitoneal cisplatin-based chemotherapy (IPCT) and intravenous cisplatin-based chemotherapy (IVCT) in stage III epithelial ovarian cancer with minimal residual disease (<1 cm) after primary debulking surgery. METHOD: One hundred and thirty-two patients with stage III epithelial ovarian cancer after optimal primary debulking surgery with minimal residual disease between April 1990 and March 1995 were entered into a randomized clinical trial in which IPCT or IVCT was administered at 3-week intervals. Patients in the IPCT arm received cisplatin-based (100 mg/m(2)) intraperitoneal chemotherapy. Patients in the IVCT arm received cisplatin-based (50 mg/m(2)) intravenous chemotherapy. The tumor response was assessed every 3 months. The hematological toxicity using the South West Oncology Group (SWOG) toxicity criteria was assessed. Catheter complications associated with intraperitoneal chemotherapy were also analyzed. RESULT: The estimated median survival in the IPCT group was 43 months (95% confidence interval, 34-54) and IVCT group was 48 months (95% confidence interval, 37-59). The hazard ratio of death was not statistically significant between IPCT and IVCT (hazard ratio, 1.13; 95% CI, 0.69-1.86; P=0.317). The frequencies of hematological toxic effects were significantly lower in the IPCT group than in the IVCT group. CONCLUSION: Intravenous and intraperitoneal chemotherapy are associated with equivalent survival in patients with minimal residual stage III epithelial ovarian cancer after optimal cytoreductive surgery.

Hyperamylasemia associated with endometroid carcinoma of the ovary.

Hyperamylasemia and alternations of serum isoamylases have been recorded in lung tumors, tubal disorders such as acute salpingitis and ruptured ectopic pregnancies and a variety of ovarian tumors, and they have been suggested as potential tumor markers. Hyperamylasemia was noted in a patient with a stage IIIC endometroid adenocarcinoma of the ovary. Serum levels of amylase decreased rapidly after removal of the ovarian tumor. In patients presenting with acute abdominal pain and elevated amylase levels, ovarian cancer should be considered in addition to acute pancreatitis.

Application of tumor markers CEA, TPA, and SCC-Ag in patients with low-risk FIGO stage IB and IIA squamous cell carcinoma of the uterine cervix.

OBJECTIVE: The aim of this study was to determine the potential clinical utility of tumor markers carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and squamous cell carcinoma antigen (SCC-Ag) in patients with FIGO stage IB and IIA squamous cell carcinoma of the uterine cervix with low-risk clinicopathologic factors (negative lymph node metastasis, no lymphovascular space involvement, no bulky tumor size, no parametrial invasion, no deep stromal invasion, and well-differentiated cellular histology). METHODS: A retrospective study was performed on 558 patients with FIGO stage IB-IIA and pathology-proven invasive squamous cell carcinoma of the uterine cervix, treated at the Veterans General Hospital, Taipei, between December 1986 and November 1990. Serum specimens were drawn before operation. A total of 140 assessable patients were enrolled into the study (including 109 stage IB patients and 31 stage IIA patients; all patients had no clinicopathologic risk factors and had at least one tumor marker datum). Survival curves were constructed according to the Kaplan-Meier method and survival curves were compared using the log-rank test. RESULTS: In univariate analysis of survival, CEA, TPA, and SCC-Ag all have roles in the prediction of prognosis. In Cox proportional hazards model using CEA, TPA, and SCC-Ag as covariates, TPA demonstrated the most significant risk factor (P = 0.031). CONCLUSIONS: We concluded that preoperative evaluation of serum TPA might be of great value in the prediction of survival of patients without any clinicopathologic risk factors and this special group of patients should be paid much attention in the follow-up period. From this study, preoperative elevation of TPA defines a group of otherwise low-risk invasive cervical cancer patients who are at high risk for recurrence. Adjuvant therapy might be necessary for this special subset of patients. A prospective study with a larger sample should be conducted to prove this particular finding.

Review of pre-eclampsia in Taiwan: a multi-institutional study.

BACKGROUND: Because the reported frequency of pre-eclampsia in Taiwan varies significantly, the aims of this study were to measure the current incidence of pre-eclampsia and its correlated morbidity and mortality for both mothers and fetuses in Taiwan. METHODS: We retrospectively studied all reported cases of pre-eclampsia and eclampsia from January 1, 1993 to December 31, 1997 in the 14 tertiary medical centers and regional hospitals in Taiwan. Recruiting criteria were pregnancy-induced hypertension (systolic blood pressure > or = 140 mmHg or diastolic blood pressure > or = 90 mmHg) with proteinuria (> or = 300 mg of urinary protein per 24 hours) and independent part edema. RESULTS: There were 4,193 patients with pre-eclampsia and eclampsia for a frequency of 2.03% of 206,551 deliveries during the study period. Of these, 58.9% of patients were classified as having mild pre-eclampsia while 38.4% had severe pre-eclampsia. Advanced maternal age (> 35 years) (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 4.23-4.90; p < 0.001), primiparity (OR = 1.71; 95% CI = 1.61-1.82; p = 0.02) and twin pregnancy (OR = 1.92; 95% CI = 1.64-2.25; p = 0.01) were significant risk factors for developing pre-eclampsia. However, multivariate analysis showed that only advanced maternal age was a significant risk factor for pre-eclampsia (OR = 3.21; 95% CI = 2.95-3.50; p < 0.001). In contrast to mild pre-eclampsia, severe pre-eclampsia resulted in significantly worse outcomes for both mothers and fetuses. Complications in patients with severe pre-eclampsia included placental abruption, acute renal failure, pulmonary edema, postpartum hemorrhage, pleural effusion, preterm labor, intrauterine growth retardation, stillbirth, neonatal mortality and low birth weight infants, all of which occurred significantly more frequently than in patients with mild pre-eclampsia (p < 0.001). CONCLUSIONS: Pre-eclampsia remains a big challenge in modern obstetrics in Taiwan. Early diagnosis and management of patients with pre-eclampsia to prevent progression would significantly improve outcomes for mothers and fetuses.

Treatment of primary pure angiosarcoma of ovary with multiple lung metastases: a case report.

Angiosarcomas rarely involve the female genital tract. There have only been sporadic case reports of angiosarcomas of the cervix, uterus, vagina, parametrium, broad ligament and pelvis, and only 11 well-documented case reports of primary ovarian angiosarcoma in the English language literature to date. We present a case of primary pure ovarian angiosarcoma with lung metastasis that had partial response after chemotherapy with adriamycin and ifosfamide. But pulmonary hemorrhage and respiratory failure resulted in her death 7 months after initial diagnosis.

Urethral diverticulum presenting with chronic pelvic pain: a case report.

Urethral diverticula are rarely encountered in the gynecologic out-patient setting. However, this condition probably occurs more frequently than it is diagnosed. The patient frequently notes signs of lower urinary tract irritation. Urinary dribbling accompanied with dyspareunia and dysuria constitutes a classic triad for urethral diverticula. Symptoms of chronic pelvic pain only occur in a minority of patients. We report a case of urethral diverticulum presenting chiefly with chronic pelvic pain. The patient underwent multiple investigative operations before a correct diagnosis was made. When confronted with a patient presenting with chronic pelvic pain, a gynecologist should retain a high index of suspicion for a urethral diverticulum in addition to other gynecologic conditions.

Prognosis-predicting system based on factors related to survival of cervical carcinoma.

OBJECTIVE: To establish a different category system based on grouping of the risk factors in patients with cervical smear. METHODS: Univariate and multivariate analyses of factors associated with survival time were performed in 443 patients with stage Ib-IIa squamous cell carcinoma (SCC) from 1985 to 1989. RESULTS: Univariate analysis showed that parametrial extension, bulky tumor size (> or = 4 cm), uterine body involvement, poor differentiation and pelvic lymph node (LN) metastasis were prognostically significant. However, by multiple regression method, only LN metastasis, deep stromal invasion (DSI), and poor differentiation (PD) were significantly related to the patient's survival time with risk ratios of 2.78, 2.61 and 1.52, respectively. A prognosis-predicting system was established on the basis of these simplified factors: groups of high, intermediate, low and very low-risks, obtained survival rates of 93-96%, 77%, 51% and 25-37%, respectively. CONCLUSIONS: Using this simple model, cervical carcinomas can be classified prognostically for predicting 5-year-survival rates, and for risk-guided therapy in the future.

Delayed postpartum hemorrhage in adenomyosis: a case report.

Adenomyosis of the uterus is a serious problem for women of reproductive age because of its possible consequence of infertility. We present the case of a woman who had adenomyosis of the uterus, a successful spontaneous pregnancy, and delayed and tenacious postpartum hemorrhage that did not respond to conservative treatment. The 26-year-old woman, gravida 1, para 1, suffered from fulminating vaginal bleeding and associated shock 20 days after the delivery of a 3,450-g female by Cesarean section. Conservative treatment included uterine compression and massage, blood transfusion, intravenous administration of high-dosage estrogen, oxytocin and sulprostone (prostaglandin E analogue), and gauze packing from the vagina into the uterine cavity. Despite treatment, the patient went into shock due to persistent vaginal bleeding. Emergency exploratoric assessment laparotomy was performed, followed by a stotal hysterectomy. Pathology revealed extensive adenomyosis of the uterus without other significant abnormality. The potential dangers of adenomyosis in pregnancy should not be overlooked when patients seek treatment for infertility.

Prognosis of primary fallopian tube adenocarcinoma: report of 25 patients.

PURPOSE OF INVESTIGATION: Because of the rarity of primary fallopian tube adenocarcinoma (PFTA), the optimal management has not been well-defined, especially in early-stage disease. Furthermore, prognosis of primary fallopian tube carcinoma has not been fully understood. METHODS: We retrospectively studied patients with proven surgico-pathological stage PFTA and excluded patients without a standard surgicopathological staging procedure. Twenty-five patients from 1970 to 1995 were identified. Eleven were in Stage I, four in Stage II and ten in Stage III and IV. Twenty patients received adjuvant chemotherapy with four to eight courses of CAP or CEP (cyclophosphamide 500 mg/m2, adriamycin 50 mg/m2 or epirubicin 50 mg/m2, and cisplatin 50 mg/m2 intravenously, every three weeks) regimen. One patient received two courses of chemotherapy and another received one course of chemotherapy; both followed with radiotherapy due to refusal of further chemotherapy. The remaining three patients did not receive any adjuvant therapy. RESULTS: Accumulative disease-free survival rate in spite of different st ages was 36%. Univariate analysis showed postoperative adjuvant chemotherapy, optimal debulking surgery, nulliparity, extent of the disease, and tumor differentiation as significant factors for disease-free survival of patients with PFTA. However, multivariate analysis did not show significance due to the small number of cases. CONCLUSION: Nearly half of the patients (44%) were diagnosed in early stage of PFTA, but patient survival was still disappointing. Understanding possibile risk factors for therapeutic failure and more aggressive and effective multi-modality treatments should be further defined.