Biomedical subjects
Publications and source records attributed to C C Changchien.
A 30-year-old woman complained of increasing dysmenorrhea and progressive right lower-quadrant pain after cesarean section. A pelvic mass was observed and subsequently a congenital müllerian anomaly was diagnosed upon serial examination. We report the first apparent case of hematometra of the rudimentary horn of a unicornuate uterus resulting from cesarean section.
Persistent fetal bradycardia is infrequent in prenatal life and difficult to manage optimally. It is generally attributable to sinus bradycardia due to fetal distress, blocked atrial extrasystoles, and congenital complete heart block. We reported four cases of persistent fetal bradycardia from 1995 to 1999 in our hospital. The first, second, and third cases of sustained fetal bradycardia had congenital complete heart block with positive titers for anti-Ro/SSA antibodies in both mothers and fetuses. Because of progressive fetal hydrops in the second case, the pregnancy was terminated. The first and third cases were isolated congenital complete heart block without structural anomaly. After prenatal examination the babies were followed up closely until term and both had a good prognosis without any implantation of pacemaker. In the fourth case there was no clinically known etiology associated with sustained fetal bradycardia. The fetal heart rate returned to normal after 6 weeks of follow-up and the baby was delivered without any cardiac problems. Congenital complete heart block is the most common cause of persistent fetal bradycardia. Prenatal detailed monitoring until delivery is necessary before heart failure develops. Treatment strategies (corticosteroids, ritodrine, and plasmapheresis) are debatable and may include prophylactic therapy for high-risk pregnant women.
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.
Deletion of the proximal portion of chromosome 4q is apparently rare. To our knowledge, prenatal diagnosis of the interstitial deletion of 4q12-21.1 has never been reported. We present a prenatal case of 4q deletion in association with a positive Down syndrome screening test of an elevated maternal serum free beta human chorionic gonadotrophin (beta-hCG) level. The prenatal sonogram revealed intra-uterine growth retardation (IUGR) and shortening of the femur. Facial dysmorphism included micrognathia, depressed nasal bridge and low-set ears, these anomalies were evident at the postnatal examination. All of the anomalies were consistent with those described in proximal 4q deletion syndrome. Our case suggests that chromosome studies may be indicated for patients with high maternal serum free beta-hCG and IUGR in the early second trimester.
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.
In order to outline the pathways of gastrointestinal malignancies metastasizing to the ovaries, we reviewed 103 cases of metastatic ovarian tumors, and also performed para-aortic lymph node sampling on 11 patients at operation for metastatic ovarian tumors. Of the 103 patients, 74% (26/35) with gastric cancer and 67% (45/67) with colorectal cancer had lymph node metastasis at or before the diagnosis of ovarian tumor. Intraperitoneal metastases presented in 49 and 42% of patients with gastric and with colorectal cancers, respectively. Twenty-three percent of gastric cancer patients and 25% of colorectal cancer patients presented with both lymph node and intraperitoneal metastases. The ovary was the first or among the early metastatic organs diagnosed in 51 of the 53 patients with metachronous ovarian metastases. Only 4 patients with colorectal cancer and none with gastric cancer showed parenchymal organ metastases. These 4 patients also showed intraperitoneal lesions, and 3 of these 4 patients had node metastasis. Among the 11 patients who underwent prospective para-aortic lymph node sampling during operation for the ovarian tumors, only 1 had enlarged para-aortic nodes depicted by computed tomography, 2 had grossly enlarged (>/=1.5 cm) para-aortic lymph nodes noted at surgery, and 6 of the 7 patients with gastric cancer and all 3 with colorectal cancer had metastatic nodes histologically. Among the 58 nodes taken from these patients, 67% showed metastatic foci. We concluded that lymph node metastasis is frequently seen in patients with metastatic ovarian tumors of gastrointestinal origin, and hypothesized that retrograde lymphatic spread is a likely route for the metastases.
A rare case of vulvovaginal tuberculosis is reported. A 76-year-old woman presented with a painful ulcer at the posterior fourchette and lower vagina for 6 weeks. Direct biopsy for histologic examination revealed mycobacterial infection. Anti-tuberculosis treatment was effective for this patient. We suggest prompt biopsies for suspicious vulvar or vaginal lesions.
To investigate the clinical significance of umbilical cord length in human pregnancies, 1087 deliveries at Kaohsiung Chang Gung Memorial Hospital from May 1995 to August 1995 were studied. Our data showed that male fetuses had longer cord length than female and vertex presentation had longer cord length than breech presentation. The cord length and placental weight were significantly related to the birth weight. We found that: 1) only intrauterine growth retardation was associated with the increased risk of fetal distress; 2) secondary arrest of labor and advanced gestational age were correlated with meconium stain; and 3) birth weight and presence of meconium stain were correlated with the secondary arrest (p < 0.05). However, there was no significant correlation between umbilical cord length and fetal well-being. As a result of multivariate analyses, we conclude that the umbilical cord length does not significantly correlate with either maternal age, gestational age (> or = 28 weeks), parity fetal outcome or intrauterine fetal well-being. Birth weight is the only characteristic that is correlated with cord length.
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From 1988 to May, 1992, there were 286 patients with pathology-proved carcinoma of the uterine cervix referred to Chang Gung Memorial Hospital, Kaohsiung to receive definite radiotherapy. Sixty-one (21%) patients were found to develop distant metastasis after radiotherapy for at least 2 years follow-up. By FIGO stage, the incidence of distant metastasis was as follows: I :2/39, II a:1/19, II b:20/118, III :34/101, IV a: 4/9. Eighty-five percent patients (52/61) began to develop distant metastasis within the first 2 years after radiotherapy. Twenty-three patients developed single organ metastasis, and 38 patients developed multiple organ metastasis. Lymph nodes (38 patients), lung (28 patients), bone (27 patients), and abdomen (20 patients) were the common sites of distant metastasis. Lymph nodes metastasis occurred most often at supraclavicular lymph nodes (15 patients), para-aortic lymph nodes (18 patients), and inguinal lymph nodes (5 patients). Spine (23 patients), especially the lumbar spine (20 patients) was the most common site of bony metastasis. Abdominal metastasis occurred in abdominal cavity (15 patients) or liver (5 patients). The incidence of metastasis within the first two years after radiotherapy was lung: 75% (21/28), bone: 62% (18/29), left supraclavicular lymph nodes: 60% (9/15), para-aortic lymph nodes: 72% (13/18), intra-abdominal cavity: 86% (13/15), liver: 66% (2/3), brain: 0% (0/4). The 2-year actuarial survival rate for the 61 patients after developing distant metastasis was 14%, with a median survival time of 6.4 months. There was no significant difference in survival when comparing patients with single organ metastasis and with multiple organ metastasis (p > 0.05), or patients with distant metastasis alone and with distant metastasis combined with local recurrence (p > 0.05). Otherwise, after distant metastasis twenty-three patients receiving chemotherapy or radiotherapy had a significantly higher 2-year survival rate than 38 patients receiving supportive care only after distant metastasis (34% vs. 2.4%, p < 0.05).
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.
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.
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.
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.
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.
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.
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.
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.