Treatment outcomes and unfavorable prognostic factors in patients with occult breast cancer.

AIMS: The purpose of this study was to evaluate the treatment outcomes and prognostic factors in patients with occult breast cancer (OBC). METHODS: We retrospectively analyzed 95 patients with OBC who were treated at our facility between January 1998 and June 2010. Of the 95 patients, 64 underwent mastectomy plus axillary lymph node dissection (ALND) with or without post-mastectomy radiation (Mast + ALND group), 13 underwent ALND followed by ipsilateral breast radiotherapy (BR + ALND group) and the remaining 18 were treated with ALND (ALND group). RESULTS: Patients who underwent Mast + ALND or BR + ALND had significantly improved rates of locoregional recurrence-free survival (LRFS) and recurrence/metastasis-free survival (RFS) than patients who only underwent ALND (p < 0.05). There were no significant differences in the LRFS (p = 0.718), RFS (p = 0.935) and breast cancer-specific survival (BCSS) (p = 0.991) rates between the patients who underwent Mast + ALND compared with those who received BR + ALND. Multivariate analysis revealed that patients with four or more involved lymph nodes had significantly worse outcomes (p = 0.042, HR = 4.63, 95% CI = 1.66-32.47 for BCSS and p = 0.038, HR = 3.62, 95% CI = 1.08-20.77 for RFS). CONCLUSIONS: Patients with OBC who received ALND and subsequent breast radiotherapy had similar outcomes to patients who underwent mastectomy. The presence of four or more involved lymph nodes may independently predict poor outcomes of OBC.

Screening options for Down syndrome: how women choose in real clinical setting.

OBJECTIVE: To study pregnant women's preference among various screening options for Down syndrome (DS) in routine clinical setting, and its potential association with women's demographic characteristics. METHODS: Women aged 35 years and older carrying singleton pregnancy were offered a variety of screening tests for DS before 14 weeks of gestation. Their preference was confirmed by the test they actually underwent. The association between women's choice of test and a number of demographic characteristics was studied using multinomial regression. RESULTS: Among 1967 eligible women, 619 opted for first-trimester screening test (FTS), 924 for partial integrated test (PIT), and 424 for full integrated test (FIT). Nulliparous women and working mothers were more likely to choose FTS and FIT. Women with history of subfertility were more likely to choose FIT. Women with family history of chromosomal abnormalities were more likely to choose FTS. The choice of screening test could be predicted for 49.9% of women using four demographic characteristics. CONCLUSIONS: Among older women of predominantly Chinese ethnicity, integrated test is a favorite alternative to FTS. Their choice of DS screening test can be predicted by their obstetric and socioeconomic characteristics. Many women show willingness to pay for a test with a lower false-positive rate.

Molecular differentiation and diversity of Forcipomyia taiwana (Diptera: Ceratopogonidae) based on the mitochondrial cytochrome oxidase II sequence.

Forcipomyia taiwana (Shiraki), a biting midge, is one of the most annoying blood-sucking pests in Taiwan. In this study, partial DNA sequences of cytochrome c oxidase II from 113 individuals collected from 11 locations around the island were analyzed to delineate the differentiation pattern and possible dispersal processes of F. taiwana in Taiwan. The uncorrected nucleotide divergences, composed of mostly transition substitutions, were high (up to 2.7%) among the samples. Average comparable variations (approximately equal to 0.7%) were found within and between populations. Phylogenetic analysis suggested that several distinct lineages exist and some can be found simultaneously in some populations. A relationship between sequence divergences among populations and their relative geographical distances was observed. Moreover, haplotype diversity was high in all populations, and low to middle levels (Fst = 0.004-0.288) of genetic differentiation were found among populations. Linearized calibration from sequence divergences and phylogenetic analysis showed that different ancestral lineages of F. taiwana possibly emerged as early as 0.6 million years ago. Taken together, genetic exchanges among these divergently ancestral lineages, likely caused by recent artificial events, have possibly led to the similarly diversified compositions of F. taiwana populations all around Taiwan nowadays.

Sublingual misoprostol compared to artificial rupture of membranes plus oxytocin infusion for labour induction in nulliparous women with a favourable cervix at term.

OBJECTIVES: To compare the efficacy of labour induction using sublingual misoprostol versus combined artificial rupture of membranes and oxytocin infusion for nulliparous women with a favourable cervix at term. DESIGN: Open randomised controlled trial. SETTING: Regional hospital, Hong Kong. PATIENTS: Fifty nulliparous women with a favourable cervix (Bishop score 6 or more) at term and indications for labour induction. INTERVENTIONS: With their informed consent, 100 eligible women were to be randomised to receive either sublingual misoprostol 50 micrograms every 4 hours for up to five doses or oxytocin infusion after artificial rupture of membranes. Interim analysis was planned at a sample size of 50. MAIN OUTCOME MEASURES: Vaginal delivery within 24 hours of induction. RESULTS: The study was terminated when interim analysis of the first 50 recruits showed that a significantly smaller proportion of misoprostol-treated women delivered vaginally within 24 hours of induction than in the conventional treatment group (68% vs 100%; relative risk, 0.68; 95% confidence interval, 0.51-0.91; P=0.009), although comparable numbers of women eventually delivered vaginally. The mean induction to vaginal delivery interval was 4.5 hours longer in the misoprostol group (P=0.027). After misoprostol treatment, all women went into labour. Forty percent of them delivered without oxytocin. There was no significant difference in uterine hyperstimulation rate, operative delivery rate, and neonatal outcomes. Maternal satisfaction was higher in the misoprostol group (92% vs 60%; relative risk, 1.53; 95% confidence interval, 1.09-2.16; P=0.008). CONCLUSIONS: Despite being well accepted by women, labour induction using this regimen of sublingual misoprostol is less effective in achieving vaginal delivery within 24 hours.

Universal screening of human immunodeficiency virus infection in pregnant women in Hong Kong: prospective study.

OBJECTIVE: To evaluate universal screening with an opt-out approach of pregnant women for human immunodeficiency virus infection. DESIGN: Prospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: All women booked or delivered in Kwong Wah Hospital from 1 January 1999 to 30 November 1999 were recruited. MAIN OUTCOME MEASURES: Numbers of women who received the human immunodeficiency virus antibody screening test, refused the test (and the reasons why), tested positive, and tested positive with confirmation by immunoblot study. RESULTS: A total of 5597 women were recruited and 5459 screening tests performed in this study. Of the 16 screened positive cases, three were confirmed by immunoblot study. The overall acceptance rate for the test was 97.5%. The acceptance rate among the 5191 women recruited through the hospital's booking clinic was not significantly different from that among the 406 women who did not go through the hospital's booking clinic (97.6% versus 96.6%). CONCLUSION: Universal screening of pregnant women for human immunodeficiency virus infection with an opt-out approach is practical, feasible, and clinically acceptable in Hong Kong.

A multicentre randomized controlled trial of oral misoprostol and i.m. syntometrine in the management of the third stage of labour.

Postpartum haemorrhage accounts for nearly 28% of maternal mortality in developing countries. Syntometrine is an effective and commonly used oxytocic in preventing postpartum haemorrhage, but it requires a controlled storage environment and i.m. administration. Misoprostol is an orally active uterotonic agent. A total of 2058 patients having a singleton pregnancy, low risk for postpartum haemorrhage and vaginal delivery were randomized to receive either 1 ml syntometrine or 600 microgram misoprostol for the management of the third stage of labour. There were no significant differences between the two groups in the mean blood loss, the incidence of postpartum haemorrhage and the fall in haemoglobin concentration. The need for additional oxytocic injection was significantly higher in the misoprostol group [relative risk (RR) 1.62, 95% confidence interval (CI) 1.34-1.96], but that of manual removal of placenta was reduced (RR 0.29, 95% CI 0.09-0.87). Shivering and transient pyrexia were more common in the misoprostol group. Oral misoprostol might be used in the management of the third stage, especially in situations where the use of syntometrine is contraindicated and facilities for storage and parenteral administration of oxytocics are limited.

Findings in women with postmenopausal bleeding investigated with hysteroscopy.

Most reports on histopathological findings of postmenopausal bleeding were published before hysteroscopy was widely used. Recent studies have shown that hysteroscopic examination is better than dilatation and curettage alone in detecting intrauterine pathology. The aim of this study is to assess histopathological findings of patients presented with postmenopausal bleeding after incorporation of hysteroscopic examination. Between 1 January 1996 and 31 December 1996, a total of 199 consecutive patients presenting with postmenopausal bleeding to a regional hospital were reviewed. Patients were investigated with cervical biopsy, endometrial aspiration or hysteroscopy and curettage. Excluding patients who had hysterectomy and cervical cancer, 97% of the patients had hysteroscopic examination. The majority of patients with postmenopausal bleeding had atrophic vaginitis and/or atrophic endometrium (58.8%). Other common diagnoses were endometrial polyp (9.4%), endometrial carcinoma (9.4%) and carcinoma of the cervix (6%). Other diagnoses included submucous fibroid, endometrial hyperplasia, pyometra, ovarian cancer and urethral caruncle. Pathologies found were similar to early reports, except that incidences of submucous fibroids and endometrial polyps were higher (13.4%). We concluded that all patients with postmenopausal bleeding should be investigated thoroughly as 22% have significant pathology. Hysteroscopy is the preferred investigation because of high incidences of endometrial polyps and submucous fibroids.

Single foetal death in twin pregnancies: review of the maternal and neonatal outcomes and management.

OBJECTIVE: To review the maternal and neonatal outcomes, and management of single foetal death in twin pregnancies. DATA SOURCES: Medline literature search (1950 to 1999) and hospital audit of single antepartum foetal deaths in twin pregnancy from 1993 through 1997. DATA SELECTION: Key words for literature search: twin pregnancy/pregnancies; single fetal death/demise. DATA EXTRACTION: Data were extracted and reviewed independently by the authors. DATA SYNTHESIS: During the study period, 182 (0.76%) of 23,804 deliveries involved twin pregnancies. Seven (3.8%) of the twin pregnancies were complicated by the death of one foetus. Single foetal death in a twin pregnancy in the late second and third trimesters is associated with significant morbidity and mortality in the surviving co-twin, especially in a pregnancy involving monochorionic twins. Management should be individualised; conservative management is preferred by most obstetricians. CONCLUSION: Single foetal death in twin pregnancies should be managed in a tertiary referral centre, where intensive foetal surveillance and adequate neonatal support are available. A multidisciplinary approach should be adopted.

Ten years' experience of antenatal mean corpuscular volume screening and prenatal diagnosis for thalassaemias in Hong Kong.

OBJECTIVE: To determine the prevalence of thalassaemia carriers in Hong Kong. SUBJECTS AND METHODS: From 1988 to 1997, 25,834 (53.7%) of 48,089 mothers were screened for thalassaemias by mean corpuscular volume (MCV) at the first antenatal visit. RESULTS: In the screened population of 25,834, 2229 (8.6%) had MCV < or = 75 fl. Of these, 1121 (4.3%) were alpha-thal, 715 (2.8%) were beta-thal, 23 (0.1%) were alpha beta-thal, 57 (0.2%) were other haemoglobin variants, and 281 (1.1%) had either iron deficiency or uncertain causes. Out of 200 pregnancies at risk for homozygous alpha-thal-1 and 32 at risk for beta-thal major, 27 homozygous alpha-thal-1 and 7 beta-thal major were identified, compared favourably with the expected figures of 23 and 9. CONCLUSION: Antenatal screening for thalassaemias by MCV is simple, effective and reliable. Universal screening has a different impact as bone marrow or cord blood stem cell transplant provides cure for beta-thal major. At risk couples have, as an alternative to termination of pregnancy, the option of early detection and treatment for their affected newborns or fetuses.

Stepwise pain score analysis of the effect of local lignocaine on outpatient hysteroscopy: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the efficacy of lignocaine gel in reducing the overall pain and pain of individual steps during outpatient hysteroscopy in comparison with placebo (no anesthesia). DESIGN: A prospective, randomized, double-blind, placebo-controlled trial. SETTING: Outpatient hysteroscopy clinic in a regional hospital in Hong Kong. PATIENT(S): A total of 500 Chinese patients undergoing outpatient hysteroscopy. INTERVENTION(S): Application of lignocaine gel to the cervix during outpatient hysteroscopy. MAIN OUTCOME MEASURE(S): Mean pain score using present pain intensity, overall pain score measured by total area under the curve, and the pain score of individual steps in the procedure in patients receiving lignocaine gel were compared with those of patients having no anesthesia. The failure rate and poor-view rate in both groups were also compared. RESULT(S): There were no statistically significant differences in mean pain score, overall pain score, and pain score of individual steps between the lignocaine group and controls. The failure rate and poor-view rate also showed no statistically significant differences. CONCLUSION(S): Outpatient hysteroscopy without anesthesia is acceptable to most Chinese women, and the local application of lignocaine gel is not effective in reducing pain.

A comparison of two regimens of intravaginal misoprostol for termination of second trimester pregnancy: a randomized comparative trial.

A prospective randomized trial was conducted in 148 women to compare the efficacy of two regimens of vaginal misoprostol for termination of second trimester pregnancy. Women aged 16-40 years requesting termination of second trimester pregnancy were randomized into two groups. Women in group 1 were given vaginal misoprostol 400 microg every 3 h for a maximum of five doses in 24 h. Women in group 2 were given vaginal misoprostol 400 microg every 6 h for a maximum of three doses in 24 h. If women did not abort in 24 h, the same regimen was repeated. The median induction-abortion interval in group 1 (15.2 h) was significantly shorter (P < 0.01) than that in the group 2 (19.0 h). The percentage of women who achieved successful abortion within 48 h in group 1 (90.5%) was also significantly higher (P < 0.02) than that in group 2 (75.7%). The incidence of fever was more common in group 1 (P = 0.01). It is concluded that the regimen of vaginal misoprostol 400 microg every 3 h with maximum of five doses in 24 h was more effective than the regimen of misoprostol every 6 h in termination of second trimester pregnancy.

Pilot study on the use of repeated doses of misoprostol in termination of pregnancy at less than 9 weeks of gestation.

Pregnancy was terminated by repeated doses of vaginal misoprostol in 20 women at a gestational age of less than 9 weeks. The women were given 800 microg of vaginal misoprostol as an initial dose followed by 400 microg of vaginal misoprostol every 3 h for 4 doses. Fourteen women (70%, 95% confidence interval: 48 85%) had a complete abortion. Two women (10%) had a missed abortion, and two (10%) had an ongoing pregnancy. Two women ( 10%) had an incomplete abortion. The interval between the first dose of misoprostol and the passage of tissue mass was 25.3 +/- 34.4 h (median: 15 h). The duration of vaginal bleeding was 23.6 +/- 20.4 days (median: 14 days). Side-effects were mild and there was no significant drop in hemoglobin level. Repeated doses of vaginal misoprostol may be an alternative for women who do not want surgical abortion and who live in an area where mifepristone is not available.

Vaginal misoprostol compared with vaginal gemeprost in termination of second trimester pregnancy. A randomized trial.

A prospective randomized trial was conducted in 140 women to compare the efficacy of vaginal gemeprost with vaginal misoprostol for termination of second trimester pregnancy. Women requesting termination of second trimester pregnancy were randomized into two groups. Group A women were given 1 mg vaginal gemeprost every 3 h for a maximum of five doses in the first 24 h, whereas group B women were given 400 micrograms vaginal misoprostol every 3 h for a maximum of five doses in 24 h. The median induction-abortion interval in the vaginal misoprostol group (14.1 h) was significantly shorter than that in the gemeprost group (19.5 h). The percentage of women who achieved successful abortion within 24 h in the misoprostol group (80.0%) was significantly higher than that in the gemeprost group (58.6%). There was no significant difference in the incidence of side effects between the two groups except for diarrhea, which was more common in the gemeprost group. The incidence of fever was more common in the misoprostol group. It is concluded that vaginal misoprostol is more effective than gemeprost in termination of second trimester pregnancy.

PIP: The efficacies of vaginal gemeprost and vaginal misoprostol for the termination of second-trimester pregnancies were compared in a prospective, randomized trial conducted in Hong Kong, China. 140 women 16-40 years of age requesting pregnancy termination at gestational ages of 14-20 weeks were allocated to receive either 1 mg of gemeprost every 3 hours up to 5 doses (n = 70) or 400 mcg of misoprostol every 3 hours up to 5 doses (n = 70). 56 women (80.0%) in the misoprostol group and 41 (58.6%) in the gemeprost group aborted within 24 hours. In primigravidas, the rate of successful abortion was significantly higher in the misoprostol group (83.3%) than the gemeprost group (55.3%). There were no significant between-group differences in this rate for multigravid women. The median induction-abortion interval was significantly shorter in the misoprostol group (14.1 hours) than the gemeprost group (19.5 hours). Blood loss during the procedure was similar in both groups. Although there was no significant difference in the incidence of side effects, diarrhea was less common in misoprostol acceptors (24.3%) than in women who received gemeprost (40.0%). In addition to being more effective at inducing abortion, misoprostol is substantially less expensive than gemeprost and does not require refrigerated transport and storage facilities. Thus, misoprostol, with or without mifepristone, should be the drug of choice for termination of mid-trimester pregnancies. Further studies are needed, however, to determine the optimal dose and frequency of administration.

The accuracy of intraoperative frozen section in the diagnosis of ovarian tumors.

A retrospective study of 316 ovarian neoplasms which had frozen section evaluation between January 1, 1990 to December 31, 1995 was conducted to determine the accuracy of frozen section diagnosis of ovarian neoplasms. The frozen section results were compared with final diagnoses from paraffin sections. The frozen section diagnosis was accurate in 95.2% of all cases and inaccurate in 4.8%. The positive predictive value of a positive (or malignant) frozen section was 100%, the negative predictive value of a negative (or benign) frozen section was 98.2%. The sensitivity for malignant tumors as 87%. For tumors of borderline malignancy, the sensitivity and specificity were 60% and 98.6% respectively. Of the false negative frozen section diagnoses, 73% (8 cases) occurred in tumors of borderline malignancy. We concluded that with the exception of the sensitivity for the diagnosis of tumors of borderline malignancy, the sensitivity and specificity of frozen section diagnosis for benign and overtly malignant ovarian neoplasms are high.

Second-trimester maternal serum alpha-fetoprotein and human chorionic gonadotrophin screening for Down's syndrome in Hong Kong.

Second-trimester maternal serum screening for fetal Down's syndrome is well established in many Western countries. Its usefulness and acceptability is unknown in the Asian countries. Between June 1994 and December 1996, we offered second-trimester serum AFP and hCG screening to pregnant women in Hong Kong who were less than 35 years old and without other risk factors for chromosome abnormalities. Each woman was assigned a risk of having a Down's syndrome term pregnancy by using a computer software program that took into account her age. weight, AFP and hCG MOMs. All those with a risk of one in 250 or greater were designated screen-positive, subject to the revision of gestation by ultrasound examination. 9,177 women with singleton pregnancies (93 per cent were Chinese) were screened. The uptake of screening was 75 per cent. 281 women (three per cent) were initially classified to be screen-positive. After revision of the gestation by ultrasound examination, 183 women (two per cent) were 'true' screen-positive and 164 (90 per cent) accepted the offer of amniocentesis. Eight of these pregnancies were affected by Down's syndrome and all the women elected pregnancy termination. The odds of being affected, given a positive screening result, were one in 23. Six Down's syndrome pregnancies were missed by screening programme. The detection rate was 57 per cent. The study showed that second-trimester serum screening for fetal Down's syndrome was feasible and accepted in the Hong Kong population.

Outpatient diagnostic hysteroscopy: analysis of 429 cases.

OBJECTIVE: To evaluate the diagnostic accuracy of outpatient hysteroscopy. METHODS: Outpatient CO2 hysteroscopy using video-camera for monitoring was performed on 429 patients from November 1995 to December 1996. The indications included post-menopausal bleeding (32.2%), menorrhagia (25.4%), irregular bleeding (24.7%), intermenstrual spotting (10.2%) and others (7.5%). RESULTS: Hysteroscopy was successfully performed on 420 (97.9%) patients. Although no anaesthetics were used, only two (0.47%) patients complained of severe pain during the procedure. Twenty-one (4.9%) patients had poor view due to submucosal fibroid or bloody view. There were no operative complications. Normal uterine cavity was found in 36.8% and atrophic endometrium in 34.7% of patients. The pathologies included submucosal fibroid (10.7%), endometrial polyp (5.8%) and fibroid polyp (2.8%). Five (1.2%) out of 429 patients were confirmed histologically to have endometrial carcinoma. No malignant lesions were missed. A total of 372 (86.7%) patients had histological confirmation of hysteroscopic findings. In 57 (13.2%) patients, the histological results did not correlate with the hysteroscopic findings. CONCLUSIONS: Outpatient hysteroscopy and suction curettage is a safe, cost-effective and acceptable procedure.

Conservative management of patients with histological incomplete excision of cervical intraepithelial neoplasia after large loop excision of transformation zone.

OBJECTIVE: To evaluate conservative management of patients with histological incomplete excision of CIN after large loop excision of transformation zone (LLETZ). METHODS: Two hundred and seventeen patients with high grade CIN were treated with LLETZ from October 1, 1992 to December 31, 1994. Fifty-three patients (24.4%) had incomplete excision on histology. All patients were followed up cytologically every 3 to 6 months during the first 18 months and then yearly till December 1996. Those patients with positive endocervical margins were followed up with both cervical smear and endocervical smear. RESULTS: The mean follow-up duration was 30.4 months. Ten patients were found to have persistent or recurrent disease. Five patients had second LLETZ and complete excision was achieved in 4 of them, one patient had cone biopsy and two had hysterectomy. One patient was found to have stage I a cervical cancer. CONCLUSION: A report of incomplete excision of CIN after LLETZ calls for follow-up with cytology and colposcopy and not aggressive retreatment.

Critical care in obstetrical patients: an eight-year review.

OBJECTIVE: To review the clinical characteristics and outcomes of critically ill obstetrical patients and to determine the outcome predictability using the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system. METHODS: A retrospective data collection of all obstetrical patients (n = 49) admitted for more than 24 hours to the Intensive Care Unit at Kwong Wah Hospital from 1988 to 1995 was conducted. Demographics, obstetric data, preexistent medical problems, diagnosis, days staying in the ICU and ICU related data were recorded for each patient. RESULTS: Obstetric admissions to ICU during the study period represented 0.12% of all deliveries during this period. There was a predominance of postpartum admissions and obstetric diagnosis responsible for the patients' critical illness. Massive postpartum haemorrhage was the single most common cause of ICU admission, representing 53.0% of all patients. Preeclampsia and eclampsia (14.3%), anaesthesia related complications (14.3%), and medical diseases complicating pregnancy (14.3%) were the other common disease categories for ICU admission. Two cases (4.1%) of surgical disease complicating pregnancy were admitted. The maternal mortality rate was 5.1 deaths per 100,000 total births, or 2 maternal deaths in 39,354 total deliveries in this study period. All deaths were due to nonobstetric causes. The perinatal mortality rate was 10.0% (5 cases) in this study group. CONCLUSIONS: When applying the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system in predicting the final outcome in this group of obstetric patients, we found that our obstetric patients requiring intensive care had a better outcome than predicted, as expressed by a low mortality ratio (0.25).

Second-trimester maternal urinary gonadotrophin peptide screening for fetal Down syndrome in Asian women.

Maternal urinary gonadotrophin peptide (UGP) was recently found to be elevated in second-trimester Down syndrome pregnancies. There is controversy about its screening efficacy. Data in the Asian population are scanty. We measured the UGP levels in 29 Down syndrome pregnancies and 297 controls and expressed them as a ratio of the urine creatinine concentration. Median UGP MOM was elevated to 3.44 (95 per cent confidence interval 1.99-5.13) in cases, compared with controls. UGP values were widely scattered in cases and controls with extensive overlap such that only 35 per cent of Down syndrome cases were expected to be detected at a 5 per cent false-positive rate. The data of the present study and previous reports show that there is a wide variability of gestation-specific UGP median values. UGP alone does not appear to be an effective screening marker for fetal Down syndrome.