Aera Yoon

Prognostic factors and outcomes in endometrial stromal sarcoma with the 2009 FIGO staging system: A multicenter review of 114 cases

OBJECTIVE To assess prognostic factors associated with disease-related survival in endometrial stromal sarcoma (ESS) using the 2009 FIGO staging system. METHODS From January 1990 to January 2012, 114 patients with ESS were identified at the Samsung and Asan Medical Center and data were retrospectively analyzed. RESULTS Ten (8.7%) patients died of the disease and 33 (28.9%) patients relapsed. The 5- and 10-year overall survival (OS) rates for the entire cohort were 92.6% and 87.1%, respectively, and the 5- and 10-year recurrence-free survival (RFS) rates were 71.8% and 52.1%, respectively. The estimated median survival after recurrence for the 33 patients whose tumors relapsed was 133 months (95% CI, 7.7-258.4), and 5-year survival after recurrence was 68.9%. Stage I (P=0.006), estrogen and/or progesterone receptor (ER/PR) positivity (P=0.0027), and no nodal metastasis (P=0.033) were associated with a good prognosis for OS in the univariate analysis. Ovarian preservation was revealed to be an independent predictor for poorer RFS (HR, 6.5; 95% CI, 1.23-34.19; P=0.027). Positivity for ER/PR (HR, 0.05; 95% CI, 0.006-0.4; P=0.006) and cytoreductive resection of recurrent lesions (HR, 0.14; 95% CI, 0.02-0.93; P=0.042) were independent predictors of better survival after recurrence. CONCLUSIONS Stage, expression of ER/PR, and nodal metastasis are significantly associated with OS in ESS. Bilateral salpingo-oophorectomy (BSO) as the primary treatment and cytoreductive resection of recurrent lesions should be considered for improving survival of patients with ESS.

Single-port access laparoscopic staging operation for a borderline ovarian tumor

Minimally invasive surgery is widely used in benign gynecologic diseases and may be used in malignancies. We performed a single-port access laparoscopy staging - bilateral salpingo-oophorectomy, laparoscopy-assisted vaginal hysterectomy, bilateral pelvic lymphadenectomy, infracolic omentectomy, and washing cytology - in a borderline ovarian tumor. The number of harvested pelvic lymph nodes were twenty-three and there were no intraoperative or postoperative complications. Single-port access laparoscopic staging may be performed in selected patients. The efficacy, safety, and potential benefits of this technique should be evaluated in further trials.

Robotic versus laparoscopic radical hysterectomy in cervical cancer patients: a matched-case comparative study.

Objective This study aimed to compare initial surgical outcomes and complication rates of patients with early-stage cervical cancer who underwent robotic radical hysterectomy (RRH) and conventional laparoscopic radical hysterectomy (LRH). Methods Patients diagnosed with invasive cervical cancer (International Federation of Gynecology and Obstetrics stage I-IIA) who underwent RRH (n = 23) at Samsung Medical Center from January 2008 to May 2013 were compared with matched patients who underwent LRH (n = 69) during the same period. The 2 surgical groups were matched 3:1 for variables of age, body mass index, International Federation of Gynecology and Obstetrics stage, histological subtype, tumor size, and node positivity. All patient information and surgical and postoperative follow-up data were retrospectively collected. Results Operating time was significantly longer (317 vs 236 minutes; P < 0.001) in the RRH group compared with the LRH group but mean estimated blood loss was significantly reduced in the RRH group (200 vs 350 mL; P = 0.036). Intraoperative and postoperative complications were not significantly different between the 2 groups (4.3% for RRH vs 1.45% for LRH; P = 0.439). Recurrences were 2 (8.7%) in the RRH and 7 (10.1%) in the LRH group. The overall 3-year recurrence-free survival was 91.3% in RRH group and 89.9% in the LRH group (P = 0.778). Conclusions Although operating time was longer in the RRH cases because of lesser experience on robotic platform, we showed that surgical outcomes and complication rate of RRH were comparable to those of LRH. In addition, surgical skills for LRH easily and safely translated to RRH in case of experienced laparoscopic surgeon.

Bone metastasis in primary endometrial carcinoma: features, outcomes, and predictors.

Objectives This study aimed to describe the clinicopathologic characteristics and outcomes and to assess the predictors associated with prognosis in endometrial carcinoma that developed bone metastasis. Methods A retrospective review of medical records was performed to identify the patients with endometrial carcinoma who developed bone metastasis between October 1994 and May 2012. Results Of the 1185 patients with endometrial carcinoma, 22 (1.8%) were identified with bone metastasis, and 21 patients were analyzed in the study. Seventeen (80.9%) patients had advanced-stage disease (2009 International Federation of Gynecologists and Obstetricians stages III-IV). Four (19.0%) patients had a bone lesion at the diagnosis of endometrial cancer. The median time of recurrence to the bone in 17 patients was 9 months (range, 2–43 months). The median overall survival (OS) and survival after bone metastasis of the entire cohort were 33 months (range, 9–57 months) and 15 months (range, 12–17 months), respectively. The patients with bone metastasis at recurrence had significantly longer OS than those patients with bone metastasis at diagnosis of endometrial cancer (36 vs 13 months; P = 0.042). Metastasis to extrapelvic bone was significantly associated with longer OS (46 vs 19 months; P = 0.001) and longer survival after bone metastasis (25 vs 12 months; P = 0.002). Isolated bone recurrence without extraosseous metastases and extrapelvic bone metastasis revealed independent predictors for survival after bone metastasis (hazard ratio, 0.09; 95% confidence interval, 0.01–0.67; P = 0.019 and hazard ratio, 0.07; 95% confidence interval, 0.01–0.53; P = 0.01). Conclusions In endometrial carcinoma that develops bone metastasis, isolated bone recurrence and extrapelvic bone metastasis are significant predictors of prolonged survival after the diagnosis of bone metastasis. Further researches on the optimal treatment modality and factors that have the clinical implications are warranted.

Laparoendoscopic single-site (LESS) myomectomy: characteristics of the appropriate myoma

OBJECTIVE To describe the characteristics of 35 myomas in 28 patients who underwent laparoendoscopic single-site myomectomy (LESS-M). STUDY DESIGN Retrospective analysis of 28 patients who underwent LESS-M at Samsung Medical Center from January 2009 to January 2013. RESULTS The median age of 28 patients was 34 years (range: 27-61) and median body mass index was 21.9 (range: 17.3-28.5). The median number of extracted myomas was one (range: 1-4) and the largest myoma diameter was 6cm (range: 2-15). The total number of extracted myomas was 35 and the types of extracted myoma were subserosal (16 myomas, 45.7%), intramural (nine myomas, 25.7%) and intraligamentary (seven myomas, 20%). In subserosal and intramural myoma, 21 myomas were located at the anterior wall and four myomas were located at the posterior wall of the uterus. Median operation time was 131min (range: 35-232). Estimated intraoperative blood loss was 65mL (range: 20-300), hemoglobin change was 2g/dL (range: 0.5-2.9) and hospital stay was 3 days (range: 1-4). There was no conversion to laparotomy but in one patient (3.6%), LESS-M converted to two-port laparoscopic myomectomy. There was no blood transfusion during and after operation. Intraoperative and postoperative complications did not occur. CONCLUSION Careful selection of patients considering the type and location of myomas is important for successful LESS-M. Myomas located in the anterior wall, subserosal or intraligamentary myomas are appropriate for LESS-M.

Pulmonary metastasectomy in uterine malignancy: outcomes and prognostic factors

Objective The aim of this study was to investigate outcomes in uterine cancer patients undergoing pulmonary metastasectomy and prognostic factors associated with survival after the procedure. Methods A retrospective study was performed in 29 uterine cancer patients who underwent surgical resection of pulmonary metastatic lesions at Samsung Medical Center between June 1995 and December 2011. Results Histopathology showed carcinoma in 17 patients (58.6%) and sarcoma in 12 patients (41.4%). Of the 29 patients, 17 (58.6%) had less than three pulmonary metastatic lesions. Eight (27.6%) had symptoms related to lung metastasis. The 5-year survival rate after pulmonary metastasectomy for the entire cohort was 48.2%. On univariate and multivariate analysis, the presence of pulmonary symptoms and more than three lesions of metastasis were associated with poor survival after pulmonary metastasectomy. Conclusion Pulmonary metastasectomy for uterine cancer is an acceptable treatment in selected patients. Patients with more than three pulmonary metastatic lesions and pulmonary symptoms related to lung metastasis could expect to have worse prognosis after pulmonary metastasectomy.

Contributing factors for bone metastasis in uterine cervical cancer.

Objective The purpose of this study was to describe the clinical characteristics and to assess the contributing factors in patients developing bone metastasis in uterine cervical cancer. Methods Two thousand thirteen patients had a diagnosis of uterine cervical cancer at Samsung Medical Center between June 1994 and December 2011. During the study period, 105 patients with bone metastasis were identified, and their clinicopathologic data were investigated retrospectively. Results Among 105 patients with bone metastasis, 14 patients were excluded and 91 patients were evaluable. The median bone metastasis–free survival was 27 months (range, 0–279 months). The time to bone metastasis was significantly shorter in patients with adenocarcinoma than in patients with squamous cell carcinoma (median duration, 12 vs 29 months; P = 0.016). In addition, it was shorter in patients with stage IIB to stage IV disease than in those with stage I to stage IIA disease (15 vs 22 months; P = 0.02). The median survival after bone metastasis was 10 months, longer in the patients who received radiotherapy (± chemotherapy) than in the patients who received chemotherapy alone as a salvage therapy (12 vs 7 months; P = 0.01). Initial stage, number of bone metastases, location of involved bone, and coexisting metastatic lesion were not associated with the overall survival of the patients. Conclusions Our study demonstrates that adenocarcinoma, advanced stage (IIB-IV) and initial multiple bone metastases contribute to earlier bone metastasis. Once bone metastasis was recognized, the survival of these patients was poor and no factors were identified to predict survival of those patients.

Correlation between location of transposed ovary and function in cervical cancer patients who underwent radical hysterectomy.

Objective The study investigated the association between the location of transposed ovaries and posttreatment ovarian function in patients with early cervical cancer (IB1-IIA) who underwent radical hysterectomy and ovarian transposition with or without adjuvant therapies. Methods Retrospective medical records were reviewed to enroll the patients with early cervical cancer who underwent ovarian transposition during radical hysterectomy at Samsung Medical Center between July 1995 and July 2012. Serum follicle-stimulating hormone (FSH) level was used as a surrogate marker for ovarian function. Results Twenty-one patients were enrolled. The median age and body mass index (BMI) were 31 years (range, 24–39 years) and 21.3 kg/m2 (range, 17.7–31.2 kg/m2), respectively. The median serum FSH level after treatment was 7.9 mIU/mL (range, 2.4–143.4 mIU/mL). The median distance from the iliac crest to transposed ovaries on erect plain abdominal x-ray was 0.5 cm (range, −2.7 to 5.2 cm). In multivariate analysis, posttreatment serum FSH levels were significantly associated with the location of transposed ovaries (β = −8.1, P = 0.032), concurrent chemoradiation (CCRT) as an adjuvant therapy (β = 71.08, P = 0.006), and BMI before treatment (underweight: β = −59.93, P = 0.05; overweight: β = −40.62, P = 0.041). Conclusions Location of transposed ovaries, adjuvant CCRT, and BMI before treatment may be associated with ovarian function after treatment. We suggest that ovaries should be transposed as highly as possible during radical hysterectomy to preserve ovarian function in young patients with early cervical cancer who might be a candidate for adjuvant CCRT and who have low BMI before treatment.

c-MET as a Potential Therapeutic Target in Ovarian Clear Cell Carcinoma

In this study, we investigated the therapeutic effects of c-MET inhibition in ovarian clear cell carcinoma (OCCC). Expression levels of c-MET in the epithelial ovarian cancers (EOCs) and normal ovarian tissues were evaluated using real-time PCR. To test the effects of c-MET inhibitors in OCCC cell lines, we performed MTT and apoptosis assays. We used Western blots to evaluate the expression of c-MET and its down-stream pathway. In vivo experiments were performed to test the effects of c-MET inhibitor on tumor growth in orthotopic mouse xenografts of OCCC cell line RMG1 and a patient-derived tumor xenograft (PDX) model of OCCC. c-MET expression was significantly greater in OCCCs compared with serous carcinomas and normal ovarian tissues (p < 0.001). In in vitro study, inhibition of c-MET using c-MET inhibitors (SU11274 or crizotinib) significantly decreased the proliferation, and increased the apoptosis of OCCC cells. SU11274 decreased expression of the p-c-MET proteins and blocked the phosphorylation of down-stream proteins Akt and Erk. Furthermore, SU11274 treatment significantly decreased the in vivo tumor weight in xenograft models of RMG1 cell and a PDX model for OCCC compared to control (p = 0.004 and p = 0.009, respectively).

Perioperative Outcomes of Radical Trachelectomy in Early-Stage Cervical Cancer: Vaginal Versus Laparoscopic Approaches.

Objective This study aimed to compare the laparoscopic-assisted radical vaginal trachelectomy (LARVT) and laparoscopic radical trachelectomy (LRT) surgical approaches and provide outcome data on patients who have undergone radical trachelectomy. Methods We identified patients who had undergone LARVT or LRT at Samsung Medical Center between January 2005 and March 2013. Results A total of 38 patients were identified, and 21 patients had undergone LARVT, whereas 17 patients had undergone LRT. The median age was 32 years for both groups. Most of the patients had a squamous cell carcinoma (68.4%) and International Federation of Gynecology and Obstetrics stage IB1 disease (76.3%). Twenty (52.6%) of 38 patients had tumor size greater than 2 cm. There were no significant differences between groups in the baseline characteristics except for the tumor size. Patients undergoing LRT had significantly larger tumor size than patients undergoing LARVT (median tumor size, 2.7 cm [range, 1.2–3.7] vs 2.1 cm [range, 0.4–3.0], P = 0.032). Perioperative outcomes were similar between groups except for the decline of hemoglobin after surgery. The median decline of hemoglobin indicating blood loss was significantly smaller in the LRT group than in the LARVT group (1.8 g/dL [range, 0.5–3.5] vs 2.6 g/dL [range, 0.7–6.2], P = 0.017). Intraoperative complications occurred in 2 patients (9.5%, 2/21) in LARVT group. Although 52.6% of tumors were larger than 2 cm, recurrence occurred only in 3 (7.9%) patients who underwent LARVT. Conclusions The study shows the feasibility of LRT, with the advantage of reduced blood loss. The LRT could be an alternative option for patients with large tumors. Further researches are needed to investigate the long-term outcomes.