Follow-up study in patients with no stone retrieval from the bile duct after endoscopic sphincterotomy

BACKGROUND

No stones are retrieved from the bile duct in 10-20% of patients with suspected common bile duct (CBD) stones after endoscopic sphincterotomy (EST). The clinical outcome in these patients remains unclear. This study followed patients from whom no stones were retrieved, to discover their clinical outcome.

METHODS

From October, 1990, to October, 1996, 401 patients with suspected CBD stones received EST for stone removal. Only patients from whom no stones were retrieved from the bile duct were included in this study. All enrolled patients were regularly interviewed and received liver function tests. Sonography, computerized tomography, endoscopic retrograde cholangiopancreatography (ERCP), and/or intrapapillary biopsy were performed as indicated.

RESULTS

Forty-two patients were included in this study. The indications for EST included 34 cases with filling defects in the common bile duct on ERCP and eight cases with suspected impacted stones as seen by imaging studies. After a mean follow-up period of 28.6 months (range, 1-61 months), six patients developed biliary stones, four had carcinoma of the ampulla of Vater, one was found to have intrabiliary growth of hepatocellular carcinoma, and there was no pathologic change in 31 cases. Of the six patients with formation of biliary stones, two had an intact gallbladder and four had received previous cholecystectomy. Of the four patients with ampullary tumors, three were diagnosed by intrapapillary biopsy soon after EST, and one was diagnosed nine months later.

CONCLUSIONS

Biliary problems were found in 26% of patients soon after EST, although no stones were retrieved from the bile duct. Regular follow-up is warranted.

Anti-tumor effects of d-dicentrine from the root of Lindera megaphylla

d-Dicentrine, a naturally occurring aporphine type isoquinoline alkaloid, isolated from the root of Lindera megaphylla Hemsl. (Lauraceae), was evaluated for its potential anti-cancer activity. We found d-dicentrine significantly inhibited the growth of human hepatoma cell line HuH-7 by delaying its doubling time in tissue culture. An in vitro colony forming assay showed that d-dicentrine decreased the colony formation efficiency in both hepatoma cell lines, HuH-7 and MS-G2, used in our study. Biosyntheses of the macromolecules DNA and RNA were also strongly inhibited. An MTT assay in 21 tumor cell lines also revealed that d-dicentrine was most cytotoxic to esophageal carcinoma HCE-6, lymphoma cell lines Molt-4 and CESS, leukemia cell lines HL60 and K562, and hepatoma cell line MS-G2. An in vitro tumor growing assay in the Severe Combined immunodeficiency (SCID) mice showed that intraperitoneal injection of d-dicentrine at the dose of 100 micrograms twice a week for 4 weeks significantly inhibited the tumor incidence of leukemia cell line K562 in SCID mice. All these data indicated that d-dicentrine has potential anti-tumor applications.

Correlation of serum immunoglobulin G Helicobacter pylori antibody titers with histologic and endoscopic findings in patients with dyspepsia

Serum immunoglobulin G (IgG) antibody tests are used extensively. We attempted to find out whether the titers of anti-Helicobacter pylori IgG antibody correlated with the degree of macroscopic gastrointestinal damage, the severity of antral gastritis, and the density of antral H. pylori colonization in symptomatic patients. Peripyloric antral biopsy specimens were obtained from 50 consecutive patients with dyspepsia undergoing upper gastrointestinal endoscopy. The macroscopic gastrointestinal damage and the histologic grades of antral gastritis were scored by a modified Lanza scale and Sydney system, respectively. In addition, the densities of antral H. pylori colonization were graded semiquantitatively. Serum IgG antibodies to H. pylori were measured by enzyme-linked immunosorbent assay. Thirty-six (M/F = 29/7) of the 50 patients had H. pylori infection documented by histologic examination or rapid urease test or both. Among the subjects, the IgG antibody titers to H. pylori correlated significantly with the grades of antral polymorphonuclear cell infiltration (p = 0.002) and antral bacterial density (p = 0.01) but not with endoscopic scores, the grades of mononuclear cell infiltration, mucosal atrophy, or intestinal metaplasia (p > 0.05). In addition, endoscopic scores also were found to be significantly correlated with antral bacterial density (p = 0.049) and the grade of polymorphonuclear cell infiltration (p = 0.012). We therefore conclude that high titers of IgG antibody to H. pylori in patients with dyspepsia indicate dense H. pylori colonization and severe antral polymorphonuclear cell infiltration. However, it cannot replace endoscopic examination to evaluate the degree of macroscopic gastrointestinal damage.

Male sexual behavior is associated with LHRH neuron number in middle-aged rats

LHRH administration is reported to facilitate male sexual behavior. The aim of the present study was to investigate whether male sexual behavior is associated with the number of LHRH neurons in the forebrain in middle-aged rats. Male Long-Evans rats (18-19 months) were assigned to three groups on the basis of sexual performance: (1) group MEI consisted of rats showing complete copulatory patterns, including mounts, intromissions and ejaculations, (2) group MI was composed of rats showing mounts and intromissions, but no ejaculation and (3) group NC were non-copulators, i.e. they did not show any copulatory behavior. Young adult rats (4-5 months), displaying sexual behavior, were used as controls. Following the sexual behavior tests, the number of LHRH neurons in the medial septum (MS), organum vasculosum of the lamina terminalis (OVLT), preoptic area (POA) and anterior hypothalamus (AH) was determined by immunocytochemistry. No difference was seen in the total number of LHRH neurons in these combined brain areas between group MIE and young controls. In the three middle-aged groups, the total number of LHRH neurons was greatest in group MIE, less in group MI, and lowest in group NC. In general, a similar trend was seen separately in the MS, OVLT and POA. These results suggest that changes in the number of LHRH neurons in the forebrain, in most cases, are age-related, at least in the middle-aged rats, but they also seem to be associated with male sexual performance.

Two new puriniums and three new pyrimidines from Heterostemma brownii

Two new puriniums, heteromines D (4) and E (5), and three new pyrimidines, heteromines F (6), G (7), and H (8), were isolated from the aerial parts of Heterostemma brownii Hay. Their structures were determined as 7,9-dimethyl-2-(N,N-dimethylamino)guaninium chloride, 7,9-dimethyl-2-(N-methylamino)guaninium chloride, 6-methoxy-4-(N-methylamino)-2-(N,N-dimethylamino)-5- (N-methylformamido)pyrimidine, 6-methoxy-2,4-bis(N-methylamino)-5-(N-methylformamido)pyrimidine, and 2-amino-6-methoxy-4-(N-methylamino)-5-(N-methylformamido)-pyrimidi ne, respectively.

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

BACKGROUND

Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients.

AIMS

To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence.

METHODS

One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient.

RESULTS

During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy.

CONCLUSION

Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.

Distribution of origin of nitric oxide synthase-immunoreactive nerve fibers in the rat epididymis

Distribution of neuronal nitric oxide synthase-immunoreactive (nNOS-IR) nerve fibers and somata in the rat epididymis and major pelvic ganglia was studied by immunohistochemical methods. In the epididymis, the supply of nNOS-IR fibers was highest in the cauda and became progressively fewer toward the caput. In the cauda and corpus, nNOS-IR fibers were distributed throughout the subepithelial tissues and around the epithelial. The pattern of distribution of vasoactive intestinal polypeptide (VIP)- and tyrosine hydroxylase (TH)-immunoreactive fibers in the epididymis was similar but the latter was generally more numerous in a given region as compared to that of nNOS-IR fibers. A population of neurons in the major pelvic ganglia were nNOS-IR-, TH- or VIP-IR. Double-labeling studies revealed that few neurons in the major pelvic ganglia contained both nNOS-IR and TH-IR. Whereas nNOS-IR and VIP-IR appeared to co-localize in the same population of the pelvic ganglion cells. Similarly, nNOS-IR fibers in the epididymis were mostly VIP-positive and TH-negative. Unilateral injection of the fluorescent tracer Fluorogold into the junction between the vas deferens and the cauda labeled a population of neurons in the right and left major pelvic ganglia, some of which were also nNOS-IR. A small number of dorsal root ganglion cells contained Fluorogold and very few expressed NOS-IR. It may be concluded that nNOS-IR nerve fibers in the rat epididymis arise mainly from neurons in the major pelvic ganglia the major of which express VIP-IR but not TH-IR. The extensive supply of nNOS-immunoreactive fibers around the epithelium and throughout the subepithelial tissues suggests that NO may be closely associated with smooth muscle contraction.

When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of rebleeding

BACKGROUND

From January 1993 to December 1994, we conducted a prospective study to investigate the evolutionary change of rebleeding risk in bleeding peptic ulcers. To obviate possible confounding factors that would influence decision making for discharge of patients, subjects with coexistent acute illnesses, systemic bleeding disorders, alcoholism, and use of nonsteroidal anti-inflammatory drugs were excluded.

METHODS

Emergency endoscopies were performed in patients with hematemesis or a melena within 24 hours of admission. Ulcer lesions were divided into six categories according to endoscopic findings. The residual risks of rebleeding of each type of ulcers were calculated for 10 days, and the critical point of acceptable rebleeding risk after discharge was set at 3%.

RESULTS

Three hundred ninety-two patients with bleeding peptic ulcers completed the study. The ulcers, characterized by clean bases, red or black spots, adherent clots, nonbleeding visible vessels without local therapy, nonbleeding visible vessels with local therapy, and bleeding visible vessels with local therapy took 0, 3, 3, 4, 4, and 3 days, respectively, to decrease rebleeding risk to below the critical point. All episodes of fatal rebleeding (n = 4) occurred within 24 hours after admission.

CONCLUSIONS

Patients with clean-based ulcers can be discharged in the first day of admission. The optimal duration required for hospitalization of patients with ulcers characterized by nonbleeding visible vessels at initial endoscopy is 4 days. The remaining patients with ulcers marked by other bleeding stigmata may be discharged after a 3-day observation.

Osthole increases glycosylation of hepatitis B surface antigen and suppresses the secretion of hepatitis B virus in vitro

During screening of Chinese herbal medicines for the activities against hepatitis B virus (HBV), a known pure compound, osthole, was found to inhibit the secretion of HBV surface antigens in vitro. The secretion of hepatitis B surface antigen (HBsAg) in culture medium of MS-G2 and HuH-7 cells transfected with HBV DNA decreased by 60% to 70% after osthole treatment, without any detectable cytotoxic effects. Both 42-nm Dane particles and 22-nm subviral HBsAg particles were significantly reduced as revealed by density gradient analysis of viral particles and the endogenous; HBV DNA polymerase assay. The production of naked HBcAg particles was not changed by osthole treatment. The steady-state level of HBV-specific messenger RNA (mRNA) was not altered by osthole treatment, as revealed by Northern blot analysis, Immunoprecipitation of culture medium showed that the ratio of glycosylated versus nonglycosylated HBsAg increased after osthole treatment. Kinetic studies revealed that osthole increased the glycosylation rate of HBsAg, thus altering the ratio of glycosylated to unglycosylated HBsAg. The increase of glycosylation of HBsAg by osthole was blocked by tunicamycin, an inhibitor of protein glycosylation. We conclude that osthole suppresses the secretion of HBV in cell culture probably because of its novel function in increasing the glycosylation of HBsAg.

Gallbladder function and recurrent stones of the biliary tract in patients after endoscopic sphincterotomy

BACKGROUND

Change in gallbladder function may occur in patients with an intact gallbladder after endoscopic sphincterotomy (EST). This study was designed to evaluate the factors influencing gallbladder filling after EST and the correlation between gallbladder function and stone recurrence.

METHODS

Sixty Chinese patients with symptomatic choledocholithiasis and an intact gallbladder received EST to clear the bile ducts. They were further investigated with sphincter of Oddi manometry (SOM), quantitative cholescintigraphy (QC), and long-term clinical follow-up.

RESULTS

Fifty-six of the 60 patients in the study group were confirmed to have a loss of sphincteric function by SOM. QC showed normal gallbladder filling in 35 of these patients and delayed or non-filling in 21 patients. A significantly higher incidence of normal gallbladder filling occurred in patients with juxtapapillary diverticulum than in those without (P < 0.02), but preexisting cholecystolithiasis had no effect on it. During the follow-up period (median, 32 months: range, 9-54 months) 10 of 56 patients developed recurrent choledocholithiasis. There was no correlation between the status of gallbladder filling, preexisting cholecystolithiasis, and recurrent stones, but 9 of the 10 patients with recurrent stones had a juxtapapillary diverticulum. Repeated endoscopic treatment was satisfactory in eight patients, and only two patients received cholecystectomy.

CONCLUSIONS

EST does not alter gallbladder function in most patients. Juxtapapillary diverticulum may facilitate gallbladder filling after EST, but it is also a possible factor for recurrent choledocholithiasis.

Pituitary adenylate cyclase activating polypeptide-immunoreactivity in human spinal cord and dorsal root ganglia

Immunohistochemical studies using an antibody against pituitary adenylate cyclase activating polypeptide-38 (PACAP) were performed on spinal cords and dorsal root ganglia harvested from two human cadavers. PACAP-like immunoreactivity (PACAP-LI) was detected in nerve fibers of the superficial layers of the dorsal horn, a few of which extended into the deeper laminae and as far as the ventral horn. At the thoracic segments, additional PACAP-LI nerve fibers were seen in the lateral funiculus projecting into the intermediolateral cell column. Dorsal root ganglia contained numerous PACAP-LI cell bodies of varying intensity. As a control, immunoreactivity to calcitonin gene-related peptide (CGRP) and substance P(SP) was also studied and found to be in nerve fibers of the substantia gelatinosa of the dorsal horn and in dorsal root ganglion cells. These results show that the pattern of distribution of PACAP-LI in the human spinal cord and dorsal root ganglia is similar to that of rodents and further suggest that PACAP may participate in sensory and autonomic functions.

Dopamine release in the nucleus accumbens during sexual behavior in prenatally stressed adult male rats

In vivo microdialysis experiments were performed on the nucleus accumbens (NAc) during observation of sexual behavior (including motivation and copulation) to determine if there were any changes in NAc dopamine (DA) transmission in prenatally stressed (PS) adult male rats. Approximate 37% of control males and 83% of PS males did not exhibit copulation during the sexual behavior tests and no significant changes in NAc DA release were seen during exposure to estrous females. In contrast, both control and PS males that displayed copulatory behavior showed a marked increase in NAc DA release when presented with a sexually receptive female behind a screen and this increased further during actual copulation. The increase in DA release in copulatory PS males was not significantly different from that in sexually active control males. In addition, a similar extent in DA release induced by high potassium perfusate was observed in all rats. These results suggest that prenatal stress may result in a deficit in DA neurotransmission in the NAc and this deficit may possibly cause impaired male sexual behavior in rats.

Effects of age on dopamine release in the nucleus accumbens and amphetamine-induced locomotor activity in rats

The effects of age on dopamine (DA) release in the nucleus accumbens (NAc) and on amphetamine (AMPH)-induced locomotor activity were studied by microdialysis in freely-moving young (5 month) and old (24 month) rats. Both basal extracellular DA and 3,4-dihydroxyphenylacetic acid (DOPAC) release and that following intra-accumbens perfusion of AMPH (1-10 microM) were significantly lower in old rats. After intraperitoneal injection of AMPH (1.5 mg/kg), no age-related change in DA release was seen in the NAc, but locomotor activity was found to increase much more in young rats than in old ones. These results indicate that (1) old rats show decreased extracellular DA and DOPAC release, both in the basal state and following intra-accumbens infusion of AMPH, and (2) the age-related locomotor activity induced by systemic injection of AMPH is not paralleled by changes in DA release in the NAc.

Factors influencing the success rates of endoscopic nasobiliary drainage in treatment of obstructive jaundice

BACKGROUND

Endoscopic nasobiliary drainage (ENBD) is a safe and effective modality which has been well documented for obstructive jaundice. However, factors predicting success rate of ENBD remain inconclusively. This study analyses those factors and discusses the outcome of patients with obstructive jaundice.

METHODS

One hundred and sixteen patients (male 99, female 17; mean age 68.2 years) with obstructive jaundice received ENBD after endoscopic retrograde cholangiogram (ERC) by Olympus JF-lT20 endoscope and 7F Wilson-Cook nasobiliary catheter from Sep. 1990 to Oct. 1993. Bile output (QD), serum bilirubin (BIW), liver biochemistry (QW), bile culture (next day), blood culture (if BT > 38.5 degrees C) were checked until definite treatment or death. Adequate drainage was defined as a daily output of bile more than 200cc, a gradual drop in serum bilirubin and no signs of cholangitis. Factors such as causes of jaundice, obstruction level, serum bilirubin, albumin, juxtapapillary diverticulum (JPD), bacteremia, fever before ERCP and ascites were analyzed.

RESULTS

The success rate was 86.2% (100/116) in ERC and 78% (78/100) in ENBD. Adequate biliary drainage was 82.1% (64/78), and serum bilirubin was reduced from 14.3 +/- 8.5 mg% to 7.5 +/- 5.6 mg% within one week. In patients with non-cancerous causes, higher success rate and adequate drainage rate were obtained compared with those with cancerous causes (94.3% vs. 69.2%, p < 0.01 and 88.6% vs. 50.8%, p < 0.01, respectively). In all patients, a higher success rate was achieved at the obstruction level at the common bile duct (CBD) compared with periampullary and hilar levels (90.7% vs 69.2%, p < 0.05 and 90.7% vs 28.6%, p < 0.001, respectively). In patients with cancer as a cause, higher success rate was achieved at CBD level than at hilar level (85% vs 28.6%, p < 0.05). Those patients with cancer and serum bilirubin above 15 mg/dl had a higher failure rate in ENBD. Success rate of ENBD was not related to the presence of JPD, bacteremia or fever before ERCP and serum albumin level.

CONCLUSIONS

Factors decreasing the success rates of ENBD were underlying cancerous causes, obstruction level at hilum or periampullary region and serum bilirubin level more than 15 mg%.

Effects of fetal brain grafting on adult behavioral masculinization and defeminization in neonatally androgenized female rats

Treatment of neonatal female rats with androgen results not only in decreased female sexual behavior but also in enhanced male sexual behavior examined in adulthood. The effects of grafting fetal preoptic area (POA) neurons into the POA, and fetal hypothalamic (HPT) neurons into the ventromedial hypothalamus (VMH), were tested in neonatally androgen-sterilized rats (ASR). The rats were injected subcutaneously with 80 micrograms testosterone propionate within the 24 hours after birth to see if sexual behavior could be normalized by fetal brain grafts. In repeated tests on ASR grafted with fetal HPT into the VMH, the lordotic response was seen to increase to the level seen in non-ASR controls, while the increase in mounting behavior in ASR was suppressed following grafting of fetal POA or cerebral cortex into the POA. These results suggest that there are dysfunctions of POA and VMH in ASR, and that the dysfunctions revealed by sexual behavior can be overcome by fetal POA or HPT grafting.

Endoscopic injection sclerotherapy vs. endoscopic variceal ligation in arresting acute variceal bleeding for patients with advanced hepatocellular carcinoma

Patients with advanced hepatocellular carcinoma and acute esophageal variceal bleeding have a very poor prognosis. To compare the efficacy and complications of sclerotherapy and banding ligation, patients with acute esophageal variceal bleeding and concomitant hepatocellular carcinoma were randomly allocated to receive either sclerotherapy (endoscopic injection sclerotherapy group, 27 patients) or banding ligation (endoscopic variceal ligation group, 30 patients). All patients received treatment within 24 h of index bleeding. Initial control of bleeding was achieved in 41% of the endoscopic injection sclerotherapy group and 87% of the endoscopic variceal ligation group (p < 0.001). The re-bleeding rates were 73% and 42%, respectively (p < 0.05). The amount of blood transfused during the week after treatment was significantly higher in the endoscopic injection sclerotherapy than in the endoscopic variceal ligation group (3.9 +/- 1.5 vs. 1.5 +/- 0.8 units, respectively) (p < 0.01). Major complications were more often encountered in the endoscopic injection sclerotherapy group (22%) than in the endoscopic variceal ligation group (3%) (p < 0.05). Twenty-three patients in the endoscopic injection sclerotherapy group and 25 patients in the endoscopic variceal ligation group have so far died. The mean survival was 25 +/- 16 days in the endoscopic injection sclerotherapy group and 49 +/- 14 days in the endoscopic variceal ligation group (p < 0.05). Variceal bleeding was the main cause of mortality in the endoscopic injection sclerotherapy group (70%), whereas in the endoscopic variceal ligation group, hepatic failure (48%), rather than variceal bleeding (28%), was the major cause.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum and ascitic concentration of C3, C4 and protein in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND

Lower concentration of ascitic or serum complement (C3, C4) or protein has been reported to participate in the development of spontaneous bacterial peritonitis (SBP). In Taiwan, the etiology of hepatic cirrhosis is mainly post-hepatic and SBP is the common complication. This study aims to determine the role of protein and complements in the pathogenesis of SBP.

METHODS

119 cirrhotic patients were divided into two groups, 30 SBP and 89 non-SBP. The concentrations of ascitic and serum complement and protein were measured for comparison.

RESULTS

The ascitic and serum C3, C4 and protein levels were significantly lower (P < 0.05) in patients with SBP than in non-SBP patients. No significant differences were noted in the ascites/serum ratio of C3, C4 and protein in patient with or without SBP.

CONCLUSIONS

Low levels of ascitic and serum protein and complements, C3 and C4, may be prone to develop SBP in our patients mostly with post-hepatitic cirrhosis.

[A report of fertilizer-spreading experiment of Scutellaria baicalensis Georgi]

The result shows that all the three kinds of fertilizers nitrogen, phosphorus and potassium can markedly raise the production of Scutellaria baicalensis. Both single spreading and mixed spreading help to enhance the yield, but mixed spreading gives higher yield--an increase of 26% over the non-spreading.

Ovarian sex cord tumor with annular tubules: a report of six cases

Six patients suffering from ovarian sex cord tumor with annular tubules (SCTAT) were reported in this article with special reference to the clinical features, histological characteristics, sex hormone profile, and management of disease. SCTAT was documented to be a estrogen-progesterone-secreting tumor based on the observations of glandular atrophy and decidual change of stroma in the endometrium and assays of steroid hormone. Menometrorrhagia followed by persistent amenorrhea and pelvic mass were presented as important clinical features. This tumor was considered as a tumor with low-grade malignancy, and retroperitoneal lymphatic metastasis was thought to be an important pathway of spread. Unilateral salpingo-oophorectomy together with ipsilateral pelvic and para-aortic lymphadenectomy were suggested as an effective treatment for SCTAT. Radiotherapy can be used for local recurrence and distant metastases.

Treatment of malignant ovarian germ cell tumors with preservation of fertility: a report of 28 cases

Preservation of fertility was carried out in 28 young patients with malignant germ cell tumors of the ovary from 1962 through 1987. The pathologic diagnosis was immature teratoma in 16, endodermal sinus tumor in 7, dysgerminoma in 2, and germ cell tumor of mixed type in 3. At laparotomy, 16 patients were proved to have stage I disease, 1 had stage II disease, 9 had stage III disease, and 2 had stage IV disease. The tumor was confined to one ovary in all 22 cases treated for the first time, and the preserved ovary and uterus were normal in all 6 referred cases with recurrent diseases. Postoperative chemotherapy was given to all patients except two with stage I immature teratoma. Persistent remission was achieved in 22 patients; 5 patients died and 1 was lost to follow-up. The duration of follow-up was more than 1 year for all surviving patients, more than 3 years in 16 cases (72.7%), and more than 5 years in 13 cases (59.1%). The menstrual periods were normal in all except 3 cases, of whom 2 were below the age of 12 and one failed to menstruate at the age of 21 with a hypoplastic uterus and underdeveloped secondary sex characters. Among 12 married patients, 7 of 10 desirous of child-birth became pregnant during follow-up. Of these, 6 had a normal term delivery and 1 is currently pregnant. The preliminary conclusion is that preservation of fertility for young patients with malignant germ cell tumors of the ovary, regardless of the stage of the disease, is a safe and practicable procedure in the absence of involvement of the contralateral ovary and uterus.

Lymph node metastasis and retroperitoneal lymphadenectomy in ovarian cancer

While clinicians are devoting themselves to the study of the behaviour of ovarian cancer as well as to the search for more effective therapeutic modalities, little attention has been paid to an important route of metastasis in this group of diseases: retroperitoneal spread through the lymphatic pathway. The purpose of this report is to present a 5-year experience of a prospective study on lymph node metastasis in patients with ovarian cancer through retroperitoneal lymphadenectomy at the Peking Union Medical College Hospital. From June 1982 through May 1987, retroperitoneal lymph node dissection was performed in 105 cases of ovarian cancer. Seventy-seven (73.3%) were histologically diagnosed as cancer of epithelial origin, and 28 (26.7%) as germ-cell tumours. The overall incidence of retroperitoneal positive nodes was 54.3% (57/105). The incidence of positive pelvic nodes was 46.7% (49/105), and that of positive para-aortic nodes was 37.5% (30/80). In 69 patients who underwent systemic lymphadenectomy, 39 were found to have glandular involvement; in these 39 patients both aortic and pelvic nodes were positive in 19 cases (48.7%), aortic nodes were positive and pelvic nodes negative in 7 cases (18.0%), and pelvic nodes were positive and aortic nodes negative in 13 cases (33.3%). Preoperative lymphography was performed in 30 cases. The positive and negative correspondence rates with the pathological findings were both 83.3%. In 38 cases in which the primary cancer originated in the left ovary, 17 (44.7%) were found to have positive pelvic nodes, whereas in 25 cases with primary cancer arising in the right ovary only 2 (8%) had metastasis of the ipsilateral pelvic nodes. The lymph nodes obtained from 22 patients with positive nodes and sufficient preoperative chemotherapy were carefully examined under the microscope for the effects of the drugs. Some cellular degeneration of the lymph node metastasis was observed in only one of the 15 cases of epithelial cancer, and no response at all was noted in three cases of immature teratoma. Cellular degeneration accompanied by extensive necrosis was demonstrated in the metastatic tumours of the lymph nodes in all four cases of endodermal sinus tumour. Seventy-two patients were followed-up for at least 2 1/2 years. The rate of complete remission was 46.7% (14/30) in patients with negative nodes, but only 33.3% (14/42) in those with positive nodes. However, the difference was not statistically significant.

Intestinal metastasis and operation in ovarian cancer: a report on 62 cases

Among numerous sites of metastasis in ovarian cancer, the most common and serious one is the intestinal tract. However, reports on ovarian malignancy with special reference to intestinal metastasis and its surgical treatment have been few. This paper is a retrospective analysis of cases of ovarian cancer with intestinal metastasis treated at the Peking Union Medical College Hospital. Sixty-two cases of ovarian cancer with intestinal metastatic tumours larger than 2 cm in diameter were treated between January 1982 and October 1987, accounting for 28.2% of a total of 221 cases of ovarian cancer admitted during the same period. Twenty-seven patients were operated on for the first time, 24 were referred from other hospitals where the cancer was considered 'inoperable' during the initial surgery, and 11 were recurrent cases. Of the 62 cases, 51 had epithelial cancer and 11 had germ-cell tumours. Metastasis to the large intestine was observed in all 62 cases, of which the rectosigmoid was involved in 59 (95.2%). Metastasis to the small bowel was observed in 26 cases (41.9%). Superficial or serosal invasion occurred in 40 cases (64.5%), and deep invasion, in which the muscularis or both muscularis and mucosa were involved, occurred in 22 cases. A complete or optimal resection of the intraperitoneal tumours was achieved in 46 cases (74.2%). Resection of metastatic tumours of the intestine was performed in 40 cases, of which a repair of the perforated intestinal wall was required in 19. Resection of the bowel was carried out in 22 cases, and a colostomy was done in 6. Postoperatively, all patients were followed up for at least 6 months. During follow-up, 17 patients (27.4%) survived, 39 died and 6 had recurrent disease. The mean survival time for 17 patients achieving complete remission was 30.3 months. Of these, ten have survived for more than 2 years, and seven for more than 3 years. The survival rate was higher in patients with germ-cell tumours and in those having superficial invasion of the intestinal wall, optimal cytoreduction of tumour and relatively sufficient postoperative chemotherapy. However, only the latter two prognostic factors were found to bear statistical significance. The role and feasibility of bowel surgery in ovarian cancer are discussed.

Lymph node metastasis of ovarian cancer: a preliminary survey of 74 cases of lymphadenectomy

Retroperitoneal lymph node dissection was performed in 74 cases of various types of ovarian malignancies. Fifty-three (71.6%) were histologically confirmed as cancer of epithelial origin and 19 (25.7%) as germ cell tumors. The results indicate that lymphatic metastasis is an exceedingly important route of spreading of this group of malignant diseases. The overall incidence of retroperitoneal positive nodes was 56.8% (42/74). In 49 cases undergoing systemic lymphadenectomy 32 were found to have glandular involvement, of which both aortic and pelvic nodes were positive in 17 cases (53.1%), aortic nodes positive but pelvic negative in six (18.8%), and pelvic nodes positive but aortic negative in nine (28.1%). In 32 cases with primary cancer that originated from the left ovary, 17 (53.1%) were found to have positive pelvic nodes, whereas in 19 cases with cancer arising from the right ovary, only one (5.3%) had metastasis of ipsilateral pelvic nodes. The routes of lymphatic spreading and the significance of lymphadenectomy in ovarian cancer are discussed.