Clinical indicators useful in decision-making about palliative chemotherapy for end-of-life ovarian cancer patients

PURPOSE

Chemotherapy for end-of-life ovarian cancer patients is a complex and delicate problem. We evaluated whether active palliative chemotherapy is beneficial for such patients using inflammatory parameters, nutritional indicators, and the PPI (Palliative Prognostic Index), which predicts short-term prognosis.

METHODS

Thirty-six patients among 49 patients who died from ovarian cancer from 2014 to 2019 at our hospital were enrolled, whom clinical and laboratory data just before starting their final chemotherapy regimen could be obtained. Associations between the time from last chemotherapy to death and the following parameters were investigated: age, performance status, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio, Modified Glasgow Prognostic Score (mGPS), Prognostic Nutritional Index (PNI) score, and PPI score.

RESULTS

The median age was 57 (range 19-80) years. The median time from last chemotherapy to death was 45.5 (range 11-110) days. Eight patients (22%) died within 30 days of their last chemotherapy regimen. In univariate analysis, median survival time was significantly shorter in patients with higher NLR, mGPS 2, and higher PPI values; NLR (≥ median vs. < median): 32 (range 11-80) days vs. 54 (range 35-110) days, p = 0.008; mGPS (2 vs. 0-1): 42 (range 11-80) days vs. 96 (range 49-110) days, p = 0.012; and PPI score (≥ median vs. < median): 38 (range 11-74) days vs. 60 (range 18-110) days, p = 0.005. However, in multivariate analysis, no factors were identified as independent prognostic factors for survival.

CONCLUSION

Parameters, such as NLR, mGPS, and PPI score, may be indicators for discontinuation of palliative chemotherapy, and may be useful for maximizing end-of-life care for ovarian cancer patients.

Usefulness of imprint cytology of gonadoblastoma with dysgerminoma in a patient with Turner syndrome and a Y chromosome: A case report and literature review

Ovarian gonadoblastoma coexisting with a dysgerminoma is extremely rare in patients with Turner syndrome (TS) and a Y chromosome. The cytological findings, including imprint cytology, of these unusual ovarian tumors have rarely been reported. We report a rare patient with a gonadoblastoma with dysgerminoma, 3.0 × 2.0 cm in size; she was a 19-year-old woman with TS and a Y chromosome. She underwent laparoscopic bilateral gonadectomy, and the tumor was classified as stage IA (pT1aNxM0) according to the International Federation of Gynecology and Obstetrics classification system. Intraoperative imprint cytology revealed two types of neoplastic cells: small tumor cells surrounding light green-stained or eosinophilic hyaline globules with marked calcification, suspicious for gonadoblastoma; and large, round, atypical cells with abundant cytoplasm, macronucleoli, and marked lymphocytic infiltration (two-cell pattern), suspicious for dysgerminoma. The cytology results in our patient may represent the second reported results of imprint cytology describing a gonadoblastoma with dysgerminoma. They are the first reported results in a patient with TS and a Y chromosome.

Prognostic significance of inflammatory parameters and nutritional index in clinical stage IVB endometrial carcinomas

Recently, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) or prognostic nutritional index (PNI) have been investigated as prognostic parameters in various malignancies. Herein, we detail how we have investigated the prognostic significance of NLR, PLR and PNI together with the other clinicopathological factors for International Federation of Gynaecology and Obstetrics stage IVB endometrial carcinoma. Thirty-two patients with clinical stage IVB disease were enrolled. The relationship between clinicopathological factors, NLR, PLR or PNI and overall survival (OS) rates was investigated. The 5-year OS rate was 9.7%, and the median survival time was 9 months. In univariate analysis, PS 0-1, G1-2 endometrioid carcinoma, occurrence of surgery, NLR (below median) and PNI (≥median) were identified as favourable prognostic factors. In multivariate analysis, only a histology (G1-2 endometrioid carcinoma) was identified as an independent favourable prognostic factor. Additional large-scale studies are required to confirm the prognostic significance of NLR, PLR and PNI in clinical stage IVB endometrial carcinoma. Impact Statement What is already known on this subject? Several parameters representing the systemic inflammatory response (e.g. neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR)) or the nutritional condition (e.g. prognostic nutritional index (PNI)) have been investigated as prognostic parameters in various malignancies, whereas they have not been thoroughly investigated in endometrial carcinoma. What the results of this study add? In univariate analysis of various factors for overall survival, the performance status (PS) 0-1, grade 1-2 endometrioid carcinoma, occurrence of surgery, NLR (below median) and PNI (≥median) were identified as favourable prognostic factors. However, in a multivariate analysis, only the histology (grade 1-2 endometrioid carcinoma) was identified as an independent favourable prognostic factor. What the implications are of these findings for clinical practice and/or further research? This retrospective study identified that neither inflammatory parameters nor the nutritional index were revealed to be independent prognostic factors by multivariate analyses. Additional large-scale studies are required to confirm the prognostic significance of NLR, PLR and PNI in clinical stage IVB endometrial carcinoma to improve the poor prognosis of this disease.

Levonorgestrel-releasing intrauterine system placement for severe uterine cervical stenosis after conization: two case reports

Background

Several approaches for treating severe uterine cervical stenosis after conization for cervical intraepithelial neoplasia have been reported; yet, the condition can still be difficult to treat successfully.

Case presentation

We performed uterine cervical dilation surgery in two patients with severe stenosis, followed by insertion of the levonorgestrel-releasing intrauterine system, which is used for dysmenorrhea or endometriosis-related pain because of its strong progesterone activity. Patient 1 was a 34-year-old Japanese woman who was diagnosed with dysmenorrhea caused by recurrent uterine cervical stenosis and hematometra after laser conization. Patient 2 was a 44-year-old Japanese woman who developed dysmenorrhea and prolonged menstruation caused by uterine cervical stenosis without hematometra. After providing informed consent, they underwent cervical dilation surgery followed by insertion of the levonorgestrel-releasing intrauterine system. After treatment, their symptoms immediately improved, and after removal of their devices, they remained asymptomatic.

Conclusions

To the best of our knowledge, this is the first report to confirm the usefulness and easy applicability of the levonorgestrel-releasing intrauterine system for uterine cervical stenosis. Although we had success with the method, this study of two patients is preliminary. Further study with larger numbers of patients is necessary to confirm the usefulness of our technique.

Complications of laser conization versus loop electrosurgical excision procedure in pre- and postmenopausal patients

Purpose ofinvestigation: The aim of this retrospective study was to compare the results and complications of laser conization and loop electrosurgical excision procedure (LEEP), performed for cervical intraepithelial neoplasia (CIN) or microinvasive carcinoma, between postmenopausal and premenopausal patients.

MATERIAL AND METHODS

This study recruited a total of 551 patients. In the laser group (n = 405), there were 361 (89.1%) premenopausal and 44 (10.9%) postmenopausal women. In the LEEP group (n = 146), there were 129 (88.4%) premenopausal and 17 (11.6%) postmenopausal women. The factors investigated in both groups were the length of the tissue cone removed and the presence of positive endocervical cone margins, residual disease, and cervical stenosis.

RESULTS

In the laser group, the length of the tissue cone was significantly longer in postmenopausal patients (17.9 ±3.9 mm vs. 15.7 ± 3.6mm; p = 0.002). The rate of positive endocervical margins was significantly higher in premenopausal patients (9.1% vs. 0%; p = 0.037). The rate of cervical stenosis was significantly higher in postmenopausal patients (59.1% vs. 8.3%; p < 0.0001). In the LEEP group, there were no differences in the length of the tissue cone (premenopausal, 11.7 ± 1.9 mm vs. postmenopausal, 11.4 ± 2.7 mm; p = 0.12), the rate of positive endocervical margins (24.0% vs. 17.6%), or the rate of residual disease (13.2% vs. 17.6%). The rate of cervical stenosis was significantly higher in postmenopausal patients (23.5% vs. 4.1%; p = 0.002); however this rate was significantly lower than that seen in the laser group.

CONCLUSION

In postmenopausal patients, the rates of positive endocervical cone margins and of residual disease were higher in the LEEP group; however, the rate of cervical stenosis was higher in the laser group. Physicians should be aware of the characteristics of the devices used for cervical conization in postmenopausal women with CIN.

Successful Laparoscopic Resection of 7 mm Ovarian Mature Cystic Teratoma Associated with Anti-NMDAR Encephalitis

Anti-NMDAR (N-methyl-D-aspartate receptor) encephalitis is an immune-mediated encephalitis. It has been predominantly described in young women and is commonly associated with an ovarian teratoma. We report a case of anti-NMDAR encephalitis associated with a 7 mm ovarian teratoma that was completely resected by laparoscopic surgery. An 18-year-old woman suddenly presented with personality changes requiring her admission to the department of neurology. After that, she also showed involuntary movements, disturbance of consciousness, and central hypoventilation. As an abdominal image revealed the possibility of a right ovarian teratoma of 5 × 7 mm, a laparoscopic operation was performed. The macroscopic appearance of the right ovary did not show any abnormalities; nevertheless, we performed a partial resection of the right ovary, with reference to the image diagnosis, in order to spare the ovarian reserve. The 22 × 22 mm partially resected ovary contained an intact 5 × 7 mm cystic tumor. The pathological diagnosis was mature cystic teratoma with components of brain tissue. An anti-NMDAR-antibody test proved positive in both serum and cerebrospinal fluid 1 month after the surgery. From these results, she was diagnosed with anti-NMDAR encephalitis. By the administration of cyclophosphamide in addition to the operation, she recovered drastically without any of the symptoms shown before.

A lip seal study of Japanese children with malocclusion

The purpose of this study was to clarify the relationship between lip seal and malocclusion in Japanese children. Fifty-three patients aged 7 to 14 years (mean 10.24 +/- 1.93) were selected randomly, and compared with 20 subjects with normal occlusion aged 7 to 14 years (mean 10.50 +/- 2.56). The subjects were divided into a good lip seal group and poor lip seal group by observing the distance between the upper and lower lip at rest. The variables that were analyzed for morphological evaluation included model analysis and cephalometric analysis. Noted for functional evaluation were tongue position, the size of the tonsils and adenoids and the oral muscle force measured by button pulling. In the evaluation of the degree of lip seal, there was no statistical difference between subjects with malocclusion and those with normal occlusion. Within the group with malocclusions, however, there were significant differences in overbite (p < 0.01), overjet (p < 0.01), and oral muscle force by button pulling (p < 0.05) between the good lip seal and poor lip seal groups. These results suggest that there is a need not only to correct malocclusion but also to be aware of lip sealing so that it may be improved in Japanese children.

Occlusal stability after extraction orthodontic therapy in adult and adolescent patients

In this study we compared the posttreatment stability of occlusion in adults and adolescents treated for crowding or maxillary protrusion with four-premolar extractions and edgewise mechanics at an average of more than 4 years out of treatment. The adolescent sample showed a significantly greater posttreatment increase in mandibular anterior crowding than the adult sample. Posttreatment overjet and overbite remained more stable in the adolescents. We noted a correlation between in-treatment expansion and posttreatment narrowing of mandibular intercanine width in the adults. Differences in postorthodontic occlusal changes were noted between the adult and adolescent samples.

Stability of occlusion after orthodontic treatment with tooth extraction in adult cases

The purpose of this study was to evaluate stability of occlusion in adult cases at least 4 years after orthodontic treatment and to clarify parameters influencing this stability. The subjects were 25 cases (mean age: 19 y 8 m) who had been treated with Edgewise technique involving first-premolar extraction. During orthodontic treatment, decreases in the maxillary and mandibular incisors' irregularity index (Max.I.I. and Mand.I.I.), posterior movement of the upper and lower incisors, increases in upper incisal height, decreases in lower incisal height, and increases in upper and lower canine width were noted. In the posttreatment period, increases in Max.I.I. and Mand.I.I., anterior movement of incisors, increases in incisal height, and decreases in canine width were observed. The amounts of overjet and overbite decreased during the treatment period and increased during the post-treatment period. Multiple regression analysis was useful to deduce which parameters influenced stability of occlusion after orthodontic treatment.

Case report of lateral crossbite. Part I. Mixed dentition

Lateral crossbite on mixed dentition does not always cause facial asymmetry or functionally abnormal movement of the mandible in children. However, it is often observed that facial asymmetry will worsen during growth in the absence of orthodontic treatment. In adult cases, lateral crossbite is one of the etiological factors of temporomandibular joint disorder. This case report presents two cases of lateral crossbite of mixed dentition. The terms of treatment were shorter than those in cases with permanent dentition. Also, methods of treatment were simpler, and the patients developed favorably. The opposite results were obtained in cases of permanent dentition.

An orthodontic study of temporomandibular joint disorders. Part 2: Clinical research in orthodontic patients

The purpose of this survey was to investigate the symptoms of temporomandibular joint disorders (TMD) in orthodontic patients and to define the relationships between symptoms and malocclusion and/or orthodontic treatment. The subjects were 532 patients, 6 to 38 year old Japanese, in the orthodontic department of Tokyo Dental College Hospital. They were examined for past or recent TMJ sounds, pain in the TMJ area, and abnormal jaw movements. The prevalence of TMJ symptoms was 33.8%. Sex differences were not statistically significant. The prevalence of TMD symptoms increased with age. TMD symptoms in young orthodontic patients (6-18 years old) were more common than in untreated subjects. Posterior crossbite and open bite patients had a high prevalence of symptoms.

[Longitudinal observation of condylar position in anterior crossbite at the mixed dentition during orthodontic treatment]

We investigated the condylar position by transcranial radiography which can be put daily clinical use easily. The patients are 8 anterior crossbite at the mixed dentition (4 functional crossbite and 4 skeletal crossbite). We observed their condylar positions before treatment (average age is 9.3 years old), after correction of overbite (average age is 10.0 years old) and 3-4 years after correction of overbite (average age is 14.0 years old). The results were as follows: 1. Condylar position of 7 cases changed after correction of overbite. The differences between right and left condylar position of six in seven cases had been recognized before treatment decreased after correction of overbite. Their condylar position were stable during the observation period of 3-4 years after correction of overbite. The condylar position of the other one case closed to fossa and then relapsed 3-4 years later. 2. Condylar position of only one case hasn't changed during the observation. 3. In functional crossbite cases, there were some differences between right and left condylar position before treatment, but no differences after crossbite correction. In skeletal crossbite cases, there was no tendency of the changing on their condylar position through treatment. 4. The changing to same direction was observed in the decrease of differences on condylar position and in the result of frontal cephalogram analysis. 5. There wasn't special relationship between changing of condylar position and orthodontic appliances. 6. TMJ dysfunction was observed in the case which has significant difference in its condylar positions before treatment and in the other case in which difference was not corrected after treatment. We recognized the usefulness of transcranial radiography for orthodontic treatment.

An orthodontic study of temporomandibular joint disorders. Part 1: Epidemiological research in Japanese 6-18 year olds

Malocclusion is considered one of the etiological factors of temporomandibular joint disorder (TMD). The purpose of this study was to investigate the prevalence of TMD and the relationship between TMD and the type of occlusion. The sample consisted of 7337 Japanese children, 6-18 years old, 3219 boys and 4118 girls. TMD symptoms were recorded as well as the type of occlusion in children with TMD. The prevalence of TMD overall was 12.2%. The prevalence increased with age and was slightly higher in girls (13%) than in boys 11.1%. This difference was not statistically significant. Joint sound as the only symptom was more common in younger subjects. TMD symptoms seemed more complicated with age when pain and abnormal jaw movement combined with sound. Joint sound was the most common symptom (89.3%), followed by the combination of sound and pain (2.2%). The incidence of other symptoms was under 1%. In subjects with TMD, 24.9% exhibited crowding, 20.1% had excessive overjet, 6.8% deep bite, 6.3% edge-to-edge bite, 5.6% anterior crossbite, 5.4% open bite, and 3.8% posterior crossbite. Morphologically normal occlusion was observed in 27.1%. In this study, many subjects with TMD had malocclusions. Early treatment may be important in the prevention of severe TMD. Although those with morphologically normal occlusions were included, a more detailed study concerning other causes of TMD is needed also.