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The diagnosis of interstitial)Tj T* 0.0113 Tc 0.0188 Tw (lung disease secondary to DM was made. Oral)Tj T* 0.0185 Tc 0.0327 Tw (prednisolone 60 mg daily and betamethasone)Tj T* 0.041 Tc 0.0736 Tw (ointment were initiated. Meanwhile the rash)Tj T* -0.0004 Tc -0.0046 Tw (remained prominent and pruritic.)Tj 0 -2.5435 TD 0.097 Tc 0.1738 Tw (Skin biopsy showed changes consistent)Tj 0 -1.273 TD 0.0952 Tc 0.1681 Tw (with a lichenoid reaction with negative)Tj T* -0.0101 Tc -0.0398 Tw (immunofluourescence. The muscle biopsy showed)Tj T* -0.0177 Tc -0.0578 Tw [(no inflammation and a normal myosin heavy chain)]TJ T* -0.0025 Tc -0.0098 Tw (1 \(MHC1\) pattern with some neurogenic features)Tj T* 0.0533 Tc 0.0965 Tw (which made autoimmune myositis unlikely.)Tj T* 0.0043 Tc 0.0065 Tw (Cancer antigen 125 \(CA125\) was 1795 kU/L at)Tj T* 0.042 Tc 0.0753 Tw [(the time \(F)18.8(igure 3\). T)101.3(ransvaginal ultrasound)]TJ 0 -1.2704 TD -0.0108 Tc -0.0344 Tw (showed a mass measuring 282932 mm in the)Tj 0 -1.273 TD -0.0091 Tc -0.0318 Tw (left adnexal region. The gynaecologist was unsure)Tj T* -0.0004 Tc -0.0037 Tw (if it was a malignant process.)Tj 0 -2.546 TD 0.0148 Tc 0.0204 Tw [(P)53.6(atient A was discharged home with follow)-16.1(-up.)]TJ 0 -1.273 TD 0.0036 Tc 0 Tw (Unfortunately, she remained dependent on high)Tj T* 0.0364 Tc 0.0576 Tw (doses of prednisolone for her dyspnoea and)Tj T* 0.0173 Tc 0.0242 Tw (hypoxia. Azathioprine was added as a steroid-)Tj T* 0.0724 Tc 0.1227 Tw (sparing agent. Even though the proximal)Tj 0 -1.2704 TD 0.077 Tc 0.1329 Tw (weakness improved significantly with the)Tj 0 -1.273 TD -0.0078 Tc -0.04 Tw (immunosuppression, persistent skin lesions on the)Tj T* 0.0183 Tc 0.0273 Tw (hands were causing significant discomfort and)Tj T* 0.0086 Tc 0.0091 Tw (distress. At six months, the option of explorative)Tj T* 0.0017 Tc -0.0042 Tw (laparoscopy was declined by the patient. At nine)Tj T* 0.0057 Tc 0.0038 Tw [(months, P)54.7(atient A presented with a new swelling)]TJ T* 0.0267 Tc 0.0403 Tw (in her left cervical region. The biopsy showed)Tj T* 0.0208 Tc 0.0328 Tw (poorly differentiated large cell carcinoma with)Tj 0 -1.2704 TD 0.0086 Tc 0.0091 Tw (weak CA125 staining which was consistent with)Tj 0 -1.273 TD 0.0146 Tc 0.0199 Tw [(ovarian cancer)94.5(. CA125 was 5815 kU/L \(F)19.7(igure)]TJ T* 0.0054 Tc 0.0038 Tw (3\). Oral cyclophosphamide was initiated for her)Tj T* 0.0395 Tc 0.0655 Tw (metastatic ovarian cancer. She tolerated the)Tj T* 0.0069 Tc 0.0068 Tw (chemotherapy well with a slight improvement in)Tj T* 0.0348 Tc 0.0532 Tw (her neck swelling and skin rash. CA125 was)Tj T* -0.0038 Tc -0.0216 Tw [(216 kU/L after six cycles \(F)14.2(igure 3\). On follow)-16.7(-up)]TJ T* -0.0023 Tc -0.0177 Tw (at 15 months, she complained of new right sided)Tj T* 0.0723 Tc 0.1209 Tw (abdominal pain and fatigue. CA125 was)Tj 0 -1.2704 TD 0.0071 Tc 0.0073 Tw [(1077 kU/L \(F)14.8(igure 3\). One week later)102.4(, P)53.5(atient A)]TJ 0 -1.273 TD 0.0085 Tc 0.0099 Tw [(was re)-17.3(-admitted to hospital, critically ill. F)18.8(urther)]TJ T* 0.0644 Tc 0.1114 Tw (imaging showed gastric outlet obstruction)Tj T* 0.0897 Tc 0.1568 Tw (secondary to metastatic serosal disease)Tj ET endstream endobj 4 0 obj << /Type /XObject /Subtype /Image /Width 485 /Height 317 /BitsPerComponent 8 /ColorSpace /DeviceCMYK /Length 35007 /Filter /DCTDecode >> stream Adobed       &&&&&++++++++++    $$#$$++++++++++=""  s!1AQa"q2B#R3b$r%C4Scs5D'6Tdt& EFVU(eufv7GWgw8HXhx)9IYiy*:JZjzm!1AQa"q2#BRbr3$4CS%cs5DT &6E'dtU7()󄔤euFVfvGWgw8HXhx9IYiy*:JZjz?]~j  φ_k<XV-ٖVPB :{8]I'Mt9~;Gl4׬eY@=!F /3-fEI#fIEPwÆ|0?z]{V*"6M"$Qp) >g 'P+b37޸RNw2"L4PВzaE> p5P>tZiFkQAb@8@JS]5O 0iZ`vcxRbbJbwJ5r w>8I{V{/ƒeZ`ec=֪$M1mQQNbO^[qHʝ)AN5gH7I&V"*Q\/b`a&؋)&c@ @nzyWGqZ.~&NSfRQĈ5kA\O>M悕95 ^Ԥlok+zbq6JF_''(Fjt=3G0ӽq$mcƩa}dRڹI_Sf#ct麒IHcm`;`'CS;)e»R1p@Z0򤳑5*(\qa抺@A"2v7vfQr`OL#U&N岑?*@댖>Km b2m#4eOzkȇEcYƣcuч7t/8﷾r82Fl\K5.K,^ ,#6iaՊ4s=Rԣe m0$4 h;J| M]lxNDxb|\ y^lgh** vƹV_o|04f5'wk>wؑڤsh^Q)WIܓDTQ?dP ֦[01)?w iCq)I؟E }E}z-vZa\oxW vR{\qӊʠ>Ш`&3q#Ջ2h #;m,drj5וp-hlޜ 8sIՅTQ{ $ Ѻ3J8rJK(|d eBDFDj>ZG#^P/Z|F{Ӷ9hq鑉ݸܹrJ44bLXS0$oڃ@ z,z{e¿tR"UNZ0:B5޸ՕT-Fe9BLPu9\IqsDPGMs=lB) #:o|rk`,q7@ F(v^V H03I ح)H ޝ7nk5?k%AȄlۧlm❋l|b@?h*r9DeKۧJChM~84lk2re=X !Esl`}{8<2ʕEj!xmqu`? ۥqPI~.|mm^&6#gUJ*]KHuoqr8Ddcul6O~ 5J\{Jxg7G\ZfaȐ@y F*<),t=1]( ZU؞5&AǙ uM9A4N9=0 %@ aS\jҸ+RwƸmlOA\qqkTW gƘI2)F A\ur&g+ ;wqJuSㅓNScNc&6$+l|q~)ɫ&ۺTSZ?ReR9!.i`'^, hA2)69SlU{LܺTJ*3RFZ^fUٳ[ [HqM9¼MD>Ue6S/(S odkv[ Z<XDV8!ME%_} ]bcNRʴ1ܜؚr#ߩyLORE+i^,'H Q ];V#$TUG)PI G+'.`| ='AWTq\Ѕ50 xLbD,:7$ׯ`}JI4r\ Pjf[ch}94e^W5/d$qlu~MeŲ%Aܜ =KF 눴{S,*be6GwVDaQtn ui3S50TU^)Lj;cIٻl4j  F4kSϤs. 3v xZHƟeBZrM8Gsr43f#<˾lO>6#S 1CmbDRkt́rz:]1v4zoefv۩ۉ(Ut/v䨓= K xbfp'}#" 10xb R 똹N\HJ5 doLHYu =q@;er''] rOL9:9X](.Z*98)bBrr$YBHҘS F-2I4⑳"'u' TGȚXHAېz|V\@);w߶n z۪;e׷\W pTr+0|2$::`{ve`Ha}> ƃ'7ܘ("ܚ60炬]=-*\7߆|ahjb$'*Chq!Gnpdz:Pzcu+A*FkeeI mNTLJv2lG]ډsdy,-$<wa1AhKތji ۓߎK f^Ğ҇Lm|w6}آ[TJ<=Gʹu5sN}2䟄TxpvSlzW-Yy-f@@j#NfV}1'GMQuuaQOCdMGs·0[e'kR"ኢW=$`WsdKܒ~)/*飳}8BѴ4˺#TZ|{!$oL^ŧh^ BAMd|B|5nOԅ\\_N#j \wz[";w=05yԐQһ EqӑҘ;0Mq,ߧς?I*I'LH᫵?Pn~ʒ;|(W֮n+ZVC}V?插CG,þ2hDL#|t+hq200]%QZS';s^!.yH2/`0^ڌ7លpI:1 0$KpJ"=CrUXA u u|!4̱Icvʼ,(=`r[QV4e"@ܑXϟ[X#\9 1FFƀt|B(As$vfĥl|3orχ љ%ŹߎR3G#HH.܏ZD4 S-\Te8ɉĊL6^њ(#7qꓥ9Nؘ#_ nkcQT{ޣDqM~(&«!jԏAt$Z1l p€b N`pӵP JҘTI~2N [^:5 EXRBv8nENK!{:\t=p`GbG_h"!5xf(| ##ڃ'rI`n)ɜ(>O1=izLP7r7'1XPmu{X}m_ͪ@@\;/Aj§cgX8(KɖY%rO0ƪX))FWfsk#. k6k=sdw xaw5 uޣomg\Fn5,<pCZя0G^8pFt#3}u^DE/Bt `Aru<^_8NzQ ; 2ٛqͽ$dz|ps!uqzUN@$Sxc+01=񢶕;5a+Vc}.C͔i w-R͖[ֈ+<*udaJc1=>y^i+Pqe)7K ;Sv7"vޘ,68J=W Pö9}(B61liBA .;\cLJEO˱Q 8ٍWN, ]܎`H>oO X҅|W4yRwSFJV*"3z$ٛ!q i4ϢC0ɾrZY1qǯlSvŹ.>am+#|xH?$R3B,W+ R|pxbbvO-oeTq\͉CʾjFA^Dԍї냽qބeG:{oJ3>ƃLBP>K놯 FsǙeR*ȴ/Olnþ؂YY!ܱdpGXc@  `e~"do`$ Ok=v#F=rf q4ѹ+#e9!ʧ⴩&Vߩ=k$Q(1-v]"M0( Gn qHJBH#*S5!#qt$ PAꏉjn6 ZZzዧol7(7!hqyX(-:L3f $p2x%]pR6QDE59)e{8fJ"`fbq9QC:lʴsHN\%Ҿ2%L^&Wo끃FRm!aŽ:sBH>ElkӾPCV3>߃x\Ý=U{xNQхlA$>;X(r܎G\Kk懌CQ?βLR$z`W}epћw/Gz]fqsc_Ӑ9FazĤ@*G! 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Sadly, she)Tj 0 -1.273 TD 0.0028 Tc -0.0031 Tw (died three weeks later.)Tj /TT1 1 Tf 13 0 0 13 56.7175 292.4683 Tm -0.0005 Tc 0.0039 Tw [(P)18.4(atient B)]TJ /TT4 1 Tf 12 0 0 12 56.7175 264.7738 Tm -0.0099 Tc -0.0315 Tw (Time to diagnosis of ovarian cancer from the)Tj 0 -1.1669 TD -0.0003 Tc -0.0042 Tw (onset of symptoms: 8 months)Tj /TT2 1 Tf 11 0 0 11 56.7175 236.7675 Tm 0.0303 Tc 0.0461 Tw [(P)53.6(atient B was a 57-year)32.9(-)-21(old woman who was)]TJ 0 -1.273 TD 0.016 Tc 0.0227 Tw (referred for management of a worsening rash.)Tj 0 -1.2704 TD 0.0197 Tc 0.0279 Tw (The rash affected the upper limbs mainly, and)Tj 0 -1.273 TD -0.0008 Tc -0.0136 Tw (had been present for eight months along with six)Tj T* -0.0063 Tc -0.0272 Tw (months of fatigue and a weight loss of 12 kg. She)Tj T* -0.015 Tc -0.0568 Tw (noticed that it was becoming more difficult to comb)Tj T* 0.0254 Tc 0.0386 Tw (her hair. A dermatologist was consulted three)Tj T* 0.039 Tc 0.0621 Tw (months earlier and suggested psoriasis as a)Tj T* -0.002 Tc -0.0181 Tw (possible cause. Skin biopsies were unremarkable)Tj T* -0.001 Tc -0.0141 Tw [(at the time. P)53.1(atient B was investigated 18 months)]TJ T* 0.038 Tc 0.0636 Tw [(prior for post)20(-menopausal vaginal bleeding)20(.)]TJ 0 -1.2704 TD -0.0029 Tc -0.0212 Tw (Repeat transvaginal ultrasound 6 months prior to)Tj 0 -1.273 TD 0.0023 Tc -0.0045 Tw (presentation was unremarkable.)Tj /TT1 1 Tf 10 0 0 10 56.7175 395.0258 Tm -0.0003 Tc 0 Tw (Figure 3. )Tj /TT2 1 Tf 4.765 0 TD 0.0001 Tc [(P)54.4(atient A's CA125 over time.)]TJ ET q 0.2 i 52.15 693.025 486.45 -289.2 re W n /GS1 gs q 486.5396 0 0 289.2 52.15 403.825 cm /Im126 Do Q Q BT 11 0 0 11 306.1662 347.8289 Tm 0.1294 Tc 0.1845 Tw (On examination, the patient had an)Tj 0 -1.273 TD 0.0255 Tc 0.0036 Tw (erythematous and scaly scalp which extended)Tj T* 0.0171 Tc -0.0212 Tw [(onto the forehead. She had early non-)-13.8(scarring)]TJ T* 0.0411 Tc 0.0318 Tw [(alopecia \(F)20.5(igure 4\). No heliotrope rash was)]TJ T* 0.0215 Tc -0.006 Tw (noted. She had bilateral and well demarcated)Tj T* 0.0157 Tc -0.0247 Tw (erythema with mild scaling on the sun exposed)Tj 0 -1.2704 TD 0.0235 Tc -0.0005 Tw (areas of the arms. On the hands, there was a)Tj 0 -1.273 TD 0.0444 Tc 0.0386 Tw (symmetrical erythematous rash with rugged)Tj T* 0.0572 Tc 0.0609 Tw (cuticles and Gottrons papules around the)Tj T* 0.048 Tc 0.047 Tw [(metacarpophalangeal joints. P)55.7(ainful digital)]TJ T* 0.0223 Tc -0.0033 Tw [(ulcers on her toes were evident \(F)19.7(igure 5\).)]TJ 0 -2.546 TD 0.0755 Tc 0.125 Tw (She was admitted to hospital for further)Tj 0 -1.273 TD 0.0129 Tc -0.0348 Tw (management of her general symptoms and the)Tj 0 -1.2704 TD 0.041 Tc 0.0318 Tw (rash, which was initially treated with topical)Tj 0 -1.273 TD 0.0791 Tc 0.1011 Tw (steroids. 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The diagnosis of DM was made and)Tj T* 0.0136 Tc -0.0305 Tw (oral prednisolone 60 mg daily was started with)Tj T* 0.0826 Tc 0.108 Tw (significant improvement of the proximal)Tj T* 0.0211 Tc 0 Tw (weakness.)Tj ET endstream endobj 9 0 obj << /Type /XObject /Subtype /Image /Width 1013 /Height 603 /BitsPerComponent 8 /ColorSpace 23 0 R /Length 81060 /Filter /DCTDecode >> stream AdobedC       &&&&&++++++++++ ["@ s!1AQa"q2B#R3b$r%C4Scs5D'6Tdt& EFVU(eufv7GWgw8HXhx)9IYiy*:JZjz?@N 6QKpR: ?7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIy7_aIyᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl?ᛯl? hV4A4REky`@$7M68y~kS?XS6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳgṳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf~?MG迼OO5KL,ṳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lṳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳa?&t_'᧚%&Oṳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lṳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٰſbQv:/a'K sgṳf͛6lٳf͛6lٳf͛6lٳf͛6X=T!uVlٳf͛6lٳf͛-QڼT; efVڅ"r@N˛kY'#HRvejf͛6lٳfṳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lٳf͛6lb1rɨxiIu?%9gṳf͛6lٳf͛6lٳf͛6l~Li:moݿ 2BΗ?=y DV|hC-C4~^ D?w7XI$w ̪- S-|0_AlV\[/5qs\6Q?|ךn"[~hP;5]Fo4j#Nt4c(>zjiT_ʛ-O@`٭M:w߽[9o3Wv[Angj{I:y}y~O{O/Chz RF4pe:}9LZ4h4OǪ[( :o<'GԢ$Պ-$+?柘>e<ɭ鋣ڥB*ƜYD@/Fz.y XzEΏdT)&8U˗Mk]g%|èhԵ cJAEyɾX=IkoS u4gc#o v"/ 2ȮHRM,"Z2u:kJ6+N9W&~JdMm$G$Ф Ȗjz^nm%LHzA޽뒛oɿk/&ȄrX(#1;"0H_u?MӤO$]JU~B6z>{knRH`[q@ޢ D ~X״^=Px5Ib+bUt(~#v7:r/1zG,T;VEgnXmKU{hfV FCY5Δ`ʠT;6, bF;:G$r3q~N~]uFtG,~cSp8f>W}kUO{_.ԫȿm?k?^{׬OK3"E=L tMWC};V{;-86lٳf͛6lٳf͛6lٳf͛6l1oG?x]X~4_œٳgṳf͛6lٳf͛6lٳf͛6tȯ:b/By]0 _ Wq#RHAIyi-F ,::pMLG)8vZ( ]F;z?.ZP >i u`?l;~[7sGssj^Ҙ$$|,£|"5/meRu;g0յ-c[H5;f&՛LE9 eovH"+C!iP3=C]ӼcZz_Ue!U٧Yz05k{IocvDMW|pW租<ɴ;DYiP)U dˮ~HzƠ%f ~Fn@_K_o˹':`0 ;zݩ3\ u/=8R>j p;<;/)6&r#:dX̛)Db>O׵/ǭi%M h >7uȵ}?9,LAhåAsi-gyekIb(K uRzro"t tR~[G5oɗ:yٵ[/6im[O8漫_h^mp"h$G<hZ.| J篟/ۤz_"sq5 ʲ|]_Z7ZGivJ>VN[CӞizmj^G!QI&:ze7|3[j=Oҿ)-v<P\ܭKMgT򖽫hxݲ۵ܞ˨cr zHޣc𭥦$YmS$q<_ uee*E<:f$$fy+˚ w$EVMc*O|5{XMf6?Fy7H‡:ixi#4qcLwyv 7t׎mUZ8soLFI6QlRnS#*Wƽh4C_EyitnF"zDH~q_i7旖u{DA2PTwܯQ5s^~g/UBYΐjzDfުK5eՈFoUvrB5ly+'%'K?OZGw'租|˽7M'F27@=I#mfa(!_2}rQ10iI950g//wz5M>6a7Vj=n!{֘[a'c 53Bb!<,BڀLJ/7?wUGR2N\_n816[iz,eo Gw1E Q)LWr!P2 ¿iBrGbM#IZyoOB\5# 4{]{?E~N˧N3:26oIo |ѩycKEԴ z㗧G܀W0%P d!iKlr%8i4_m=+zy?~h皵mYK0Z1҃cSQ?̟.y?GGz|NѸb*Ҋ+S>`6l5(Ea,+Q]9͛6lٳf͛6lٳf͛6lٳf͛ [Q.O5c? <).12İ6lٳṳf͛6lٳf͛6lٳf͛&ySզI2Y^&E=O#iu=SK7/J^,Cm)2I@=]y??zNykhi[ .NX1~Z7g|^i6+,vR,(]+~?.˛%ya&U Wr?qez藞O楕Ν|rA*f&51y Nb͚^X  s "o0䟞OkR*{FQx49 |ͣ&h忻y[R~ <|3d"t:Y|myk0-k Ǘ4[=WCpj$6Սi3y1>}&Y[GUe$p[цry_ZymE=au$V*]d]݆6~Q1UjUQR89]GBJ)ZTX4)O|yC7 tfU VHC_vjʒ\KY/yuqȳ͙=ϩrw_\ f3k~F^WZ]rf17?տuĿ%gT-u6HGj@a'Zdʚ/|%徹6u #k[BODWgeQPё*˖?:n-7%HjaZxd? 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T)99.9(ransvaginal)]TJ T* 0.0615 Tc 0.1057 Tw (ultrasound showed a large heterogeneous)Tj T* 0.0014 Tc -0.0076 Tw (myometrial mass arising from the uterine fundus)Tj T* 0.0153 Tc 0.0214 Tw (with invasion into the endometrial cavity and a)Tj T* 0.0685 Tc 0.1164 Tw (smaller left adnexal complex cystic mass.)Tj T* -0.0061 Tc -0.0273 Tw [(CA125 was 2035 kU/L at the time \(F)19.7(igure 6\). The)]TJ T* -0.0073 Tc -0.0336 Tw (gynaecologist felt that the pelvic lesions had a low)Tj T* -0.0143 Tc -0.0545 Tw (chance of resectability and a high risk for operative)Tj 0 -1.2704 TD 0.0455 Tc 0.0772 Tw [(complications. F)17.2(ine needle aspirate showed)]TJ 0 -1.273 TD -0.009 Tc -0.0436 Tw (adenocarcinoma, cytokeratin 7 \(CK7\) and CA125)Tj ET q 0.2 i 57.5 693.175 234.45 -175.85 re W n /GS1 gs q 234.7977 0 0 175.85 57.5 517.325 cm /Im127 Do Q Q BT /TT1 1 Tf 10 0 0 10 57.4866 507.136 Tm 0.0243 Tc 0.0325 Tw (Figure 4. )Tj /TT2 1 Tf 5.0769 0 TD 0.0229 Tc 0.033 Tw (Erythematous and scaly scalp with non-)Tj -5.0769 -1.5024 TD 0.0042 Tc -0.005 Tw (scarring alopecia.)Tj ET q 0.2 i 56.7 453.525 232.45 -143.1 re W n /GS1 gs q 232.9191 0 0 143.1 56.7 310.425 cm /Im128 Do Q Q BT /TT1 1 Tf 10 0 0 10 56.6929 298.0809 Tm 0.0048 Tc 0 Tw (Figure 5. )Tj /TT2 1 Tf 4.8161 0 TD 0.0052 Tc 0.001 Tw [(P)53.8(ainful digital ulcers of the toes.)]TJ 11 0 0 11 306.1417 683.6777 Tm 0.0137 Tc 0.0191 Tw (positive, suggestive of malignancy arising from)Tj 0 -1.273 TD 0.0032 Tc -0.003 Tw (the female genital tract.)Tj 0 -2.546 TD 0.0122 Tc 0.017 Tw (Neoadjuvant chemotherapy with paclitaxel and)Tj 0 -1.273 TD 0.0376 Tc 0.0599 Tw (carboplatin was commenced and it was well)Tj T* 0.0076 Tc 0.0085 Tw [(tolerated. F)33.4(ollow)-18.2(-up CT after five cycles showed)]TJ T* 0.0211 Tc 0.033 Tw (almost complete clearance. CA125 decreased)Tj 0 -1.2704 TD -0.0119 Tc -0.0545 Tw [(significantly \(F)13.9(igure 6\). However)104.1(, despite moderate)]TJ 0 -1.273 TD 0.0135 Tc 0.0191 Tw (daily oral prednisolone \(10-20 mg\) throughout)Tj T* 0.01 Tc 0.0119 Tw (this period, she continued to be troubled by the)Tj T* -0.0058 Tc -0.0299 Tw (ulcerating lesions on the hands and elbows which)Tj T* 0.0027 Tc -0.0023 Tw (were very debilitating at times.)Tj 0 -2.546 TD -0.0092 Tc -0.0431 Tw (Unfortunately, prior to her assessment for surgery,)Tj 0 -1.273 TD 0.0183 Tc 0.0266 Tw (she was readmitted to hospital critically ill and)Tj 0 -1.2704 TD 0.0608 Tc 0.1046 Tw (deteriorated rapidly before succumbing to)Tj 0 -1.273 TD 0.0287 Tc 0.0455 Tw (aspiration and respiratory arrest. CA125 was)Tj T* 0.0029 Tc -0.0016 Tw [(2209 kU/L at the time of her death \(F)20.9(igure 6\).)]TJ /TT1 1 Tf 13 0 0 13 306.1417 404.3801 Tm -0.0003 Tc 0 Tw (Discussion)Tj /TT2 1 Tf 11 0 0 11 306.1417 376.6856 Tm 0.0486 Tc 0.0788 Tw (The incidence of dermatomyositis is 10 per)Tj T* 0 Tc -0.0104 Tw (million people and the average age of diagnosis)Tj T* 0.0047 Tc 0.0031 Tw [(is 40. W)53.7(omen are twice as likely to be affected.)]TJ 6.4 0 0 6.4 534.7841 352.336 Tm 0 Tc 0 Tw (1)Tj 11 0 0 11 306.1417 334.6762 Tm 0.0422 Tc 0.0691 Tw (DM has been associated with malignancies,)Tj T* 0.0227 Tc 0.0364 Tw (especially ovarian, lung, pancreatic, stomach,)Tj T* 0.0897 Tc 0.1606 Tw (colorectal, non-Hodgkin lymphoma and)Tj T* -0.0013 Tc -0.0182 Tw (nasopharyngeal cancers in Asians.)Tj 6.4 0 0 6.4 471.4865 296.3234 Tm 0.0001 Tc 0 Tw (2,3)Tj 11 0 0 11 480.9542 292.6667 Tm -0.0022 Tc -0.0204 Tw [( The relative)]TJ -15.8921 -1.273 TD -0.0006 Tc -0.0121 Tw (risk is highest in the first year after diagnosis and)Tj 0 -1.2704 TD 0.0026 Tc -0.0033 Tw (among patients older than 49.)Tj 6.4 0 0 6.4 453.5999 268.3171 Tm 0 Tc 0 Tw (4)Tj 11 0 0 11 306.1417 236.6825 Tm 0.0147 Tc 0.0201 Tw (In Australia, ovarian cancer is the second most)Tj 0 -1.273 TD 0.0326 Tc 0.0534 Tw (common gynaecological malignancy and the)Tj T* 0.0586 Tc 0.0981 Tw (leading cause of death from gynaecologic)Tj T* 0.0089 Tc 0 Tw (malignancies.)Tj 6.4 0 0 6.4 374.0881 198.3298 Tm 0 Tc (5)Tj 11 0 0 11 377.9432 194.6731 Tm 0.009 Tc 0.01 Tw [( Seventy percent of patients have)]TJ -6.5274 -1.273 TD 0.0392 Tc 0.0629 Tw (metastatic disease at the time of diagnosis.)Tj 6.4 0 0 6.4 534.7841 184.3266 Tm 0 Tc 0 Tw (6)Tj 11 0 0 11 306.1417 166.6668 Tm 0.0241 Tc 0.0386 Tw (Despite current multimodal therapy, including)Tj T* -0.0084 Tc -0.0443 Tw (aggressive cytoreductive surgery and combination)Tj 0 -1.2704 TD 0.0026 Tc -0.0038 Tw [(chemotherapy)87.6(, five)-20.6(-year survival rates are poor)103.1(.)]TJ 6.4 0 0 6.4 534.7841 142.3172 Tm 0 Tc 0 Tw (7)Tj 11 0 0 11 306.1417 124.6857 Tm -0.0112 Tc -0.0443 Tw (The lifetime risk of a woman being diagnosed with)Tj 0 -1.273 TD -0.0029 Tc -0.0188 Tw (ovarian cancer by the age of 75 is approximately)Tj T* 0.001 Tc -0.0074 Tw (1%. 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It has been)Tj 0 -1.273 TD -0.0081 Tc -0.0409 Tw (recognised that cutaneous lesions precede muscle)Tj T* 0.0497 Tc 0.0784 Tw (disease in one third to one half of patients)Tj T* 0.0143 Tc 0.0181 Tw (and myositis follows within 3-6 months in most)Tj T* -0.0105 Tc 0 Tw (patients.)Tj 6.4 0 0 6.4 96.119 267.0699 Tm 0 Tc (9)Tj 11 0 0 11 99.804 263.4132 Tm -0.0105 Tc -0.0525 Tw [( P)59.1(athognomonic Gottrons papules occur)]TJ -3.917 -1.2704 TD 0.0031 Tc -0.0007 Tw (in approximately 70% of patients and heliotrope)Tj 0 -1.273 TD 0.0095 Tc 0.0103 Tw (rash in 30-60% of patients during the course of)Tj T* 0.017 Tc 0.0227 Tw (the illness.)Tj 6.4 0 0 6.4 109.045 225.0888 Tm 0.025 Tc 0 Tw (10)Tj 11 0 0 11 116.8686 221.4321 Tm 0.0169 Tc 0.0241 Tw [( It is of interest that, the heliotrope)]TJ -5.4683 -1.273 TD 0.0316 Tc 0.0487 Tw (sign derives its name from the vivid lavender)Tj T* -0.0047 Tc -0.0254 Tw (flowers of a genus of flower plants, Heliotropium.)Tj T* 0.0034 Tc -0.0023 Tw (Other manifestations include mechanics hands,)Tj T* 0.0593 Tc 0.1046 Tw (periungual telangiectasias, dysphonia and)Tj T* -0.0016 Tc -0.0174 Tw (dysphagia. Not all patients have these problems.)Tj 0 -1.2704 TD 0 Tc -0.0111 Tw (However, if they are present, they should prompt)Tj 0 -1.273 TD -0.0009 Tc -0.0136 Tw (clinicians to consider skin and muscle biopsies to)Tj T* 0.002 Tc -0.0063 Tw (help with reaching a definitive diagnosis.)Tj 6.4 0 0 6.4 253.1016 113.092 Tm -0.0015 Tc 0 Tw (11)Tj 11 0 0 11 56.7175 81.429 Tm 0.0121 Tc 0.0142 Tw (Once the diagnosis of DM has been made in a)Tj T* 0.0506 Tc 0.0854 Tw (mature female patient, the clinician should)Tj 22.6772 22.9091 TD 0.0088 Tc 0.0096 Tw (proceed to investigate as to the possibility of an)Tj 0 -1.273 TD -0.0041 Tc -0.0239 Tw (underlying malignancy. Hill et al)Tj 6.4 0 0 6.4 459.2087 309.0793 Tm 0 Tc 0 Tw (2)Tj 11 0 0 11 462.9504 305.4227 Tm -0.0035 Tc -0.0257 Tw [( suggests that in)]TJ -14.2531 -1.273 TD 0.0128 Tc 0.0172 Tw (addition to routine examination and laboratory)Tj T* -0.0104 Tc -0.0448 Tw (screening, CT imaging of the chest, abdomen and)Tj T* -0.0139 Tc -0.0551 Tw (pelvis, ultrasound scan of the abdomen and pelvis,)Tj 0 -1.2704 TD -0.0118 Tc -0.0622 Tw (mammography, and gynaecological examination,)Tj 0 -1.273 TD 0.033 Tc 0.05 Tw (are justified. CA125 was used in both of our)Tj T* 0.0004 Tc -0.0125 Tw (patients for diagnosis, monitoring chemotherapy)Tj T* 0.002 Tc -0.0075 Tw (effectiveness and recurrence indication.)Tj 0 -2.546 TD -0.0023 Tc -0.0084 Tw (CA125 is a measure of epithelial antigen protein)Tj 0 -1.273 TD -0.0072 Tc -0.0241 Tw (derived from coelomic epithelium. It is also raised)Tj T* 0.019 Tc 0.0333 Tw (in pancreatic cancer as well as non-malignant)Tj 0 -1.2704 TD 0.0007 Tc 0.0009 Tw (condition such as endometriosis, benign ovarian)Tj 0 -1.273 TD -0.0085 Tc -0.0303 Tw (cysts, cirrhosis and pericarditis.)Tj 6.4 0 0 6.4 450.2512 127.0668 Tm -0.0015 Tc 0 Tw (12)Tj 11 0 0 11 457.763 123.4384 Tm -0.0087 Tc -0.0318 Tw [( CA125 is readily)]TJ -13.7815 -1.273 TD 0.0389 Tc 0.0682 Tw (available; it can be repeated at appropriate)Tj T* -0.0005 Tc -0.0039 Tw (intervals and is minimally invasive. 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