Hsu-Dong Sun

Clinical presentation and outcome of adult-type granulosa cell tumors: A retrospective study of 30 patients in a single institute

Background: Ovarian adult‐type granulosa cell tumors (GCTs) are characterized as low‐malignant and late‐recurrent ovarian tumors. Although some clinical and pathological prognostic factors have been reported, other factors have yet to be sufficiently investigated for necessary confirmation. The aim of this study was to test the correlation between clinical factors and outcome, based on patients seen in a single institute. Methods: Thirty patients with pathologically confirmed adult‐type GCTs between 1984 and 2010 were reviewed retrospectively. Among them, eight (26.7%) had recurrence, which subsequently contributed to two mortalities. Results: In a comparison of the clinical characteristics of the premenopausal and postmenopausal women with GCT, all of the postmenopausal women had symptoms (100% vs. 63.6%, p = 0.01). With regard to disease recurrence, only abnormal preoperative serum cancer antigen 125 level (≥35 U/mL) was significant (50% vs. 11%, p = 0.03), and residual tumor showed a borderline trend (100% vs. 21.4%, p = 0.06). Other factors, including International Federation of Gynecology and Obstetrics stage, tumor size, tumor rupture prior to or during operation, body mass index, parity, serum estrogen level, and adjuvant therapy, were not statistically significant. Conclusion: Physicians should be alert to the difference in the symptom presentation of GCTs between pre‐ and postmenopausal women, giving particular attention to the usefulness of the preoperative serum level of cancer antigen 125 in patients with GCTs. More evidence is needed to confirm this observation.

Women with endometriosis have higher comorbidities: Analysis of domestic data in Taiwan.

Abstract Endometriosis, defined by the presence of viable extrauterine endometrial glands and stroma, can grow or bleed cyclically, and possesses characteristics including a destructive, invasive, and metastatic nature. Since endometriosis may result in pelvic inflammation, adhesion, chronic pain, and infertility, and can progress to biologically malignant tumors, it is a long‐term major health issue in women of reproductive age. In this review, we analyze the Taiwan domestic research addressing associations between endometriosis and other diseases. Concerning malignant tumors, we identified four studies on the links between endometriosis and ovarian cancer, one on breast cancer, two on endometrial cancer, one on colorectal cancer, and one on other malignancies, as well as one on associations between endometriosis and irritable bowel syndrome, one on links with migraine headache, three on links with pelvic inflammatory diseases, four on links with infertility, four on links with obesity, four on links with chronic liver disease, four on links with rheumatoid arthritis, four on links with chronic renal disease, five on links with diabetes mellitus, and five on links with cardiovascular diseases (hypertension, hyperlipidemia, etc.). The data available to date support that women with endometriosis might be at risk of some chronic illnesses and certain malignancies, although we consider the evidence for some comorbidities to be of low quality, for example, the association between colon cancer and adenomyosis/endometriosis. We still believe that the risk of comorbidity might be higher in women with endometriosis than that we supposed before. More research is needed to determine whether women with endometriosis are really at risk of these comorbidities.

Primary gallbladder carcinoma presenting as advanced-stage ovarian cancer

Primary gallbladder carcinomas are rare and the prognosisis very poor. The incidence is 1e2% of all gastro-intestinal(GI) tract cancers [1]. Information on ovarian metastasis ofprimary gallbladder cancer is limited [2e13], partly becauseprimary gallbladder cancers are rare, and partly becausemetastases from primary gallbladder cancer are mediatedthrough either lymphatic or hematogenous routes. Sinceprimary gallbladder cancers are mucinous tumors, there areproblems with the differential diagnosis if mucinous ovariancarcinomas are found. Furthermore, primary or secondaryovarian mucinous tumors may present similar clinical symp-toms, for example, non-specific GI symptoms or signs, andsimilar findings on imaging studies or tumor marker surveys.Before and during an operation, an accurate diagnosis some-times cannot be made [14]. Herein, we present a case ofsecondary ovarian mucinous cancer emanating from primarygallbladder mucinous carcinoma.An 84-year-old woman was sent to the emergency roombecause of diffuse abdominal pain and poor appetite. Clinicalexamination showed an acutely ill-looking woman withapparent peritoneal signs (diffuse tenderness and reboundingpain) associated with a lower abdominal mass. Ultrasoundshowed a 15-cm complex cystic mass in the right adnexa, butthe uterus and the left ovary were normal. Computed tomog-raphy further identified this 15-cm ill-defined right adnexalheterogeneous mass with diffuse peritoneal seeding andcarcinomatosis. Serum tumor markers, including CA 125, CA153, CA 199, and CEA were 327.3 U/mL, 29.0 U/mL, 218.0U/mL, and 85.8 ng/mL, respectively. The other hematologicaland biochemical tests were normal. Upper and lower gastro-intestinal tract evaluations were negative.Under the diagnosis of ovarian cancer, an exploratorylaparotomy was done. A complex cystic right ovarian masswith a mucinous component was found, as well as diffusecarcinomatosis involving the entire lower and upper abdom-inal cavity, including the omentum, in which the inflamedgallbladder was embedded. Frozen section of the removedovarian tumor favored the diagnosis of primary ovariancarcinoma, mucinous type. The patient underwent a subop-timal debulking surgery, including total hysterectomy, bilateralsalpingo-oophorectomy, omentectomy, and retroperitoneallymph node sampling, and multiple biopsies. The finalpathology was primary gallbladder mucinous carcinoma.Microscopic features showed hyperchromatic dysplasia ofthe mucinous glandular cells of the gallbladder; the mucinoustumor occupied the entire cavity of the gallbladder. The tumorhad invaded whole layers of the gallbladder, and penetrated tothe outside serosa and the attachment of the omentum. Othersections of the right ovary, appendix, omentum, abdominalwall, mesentery, and right pelvic lymph nodes all showedtumor metastases with floating mucinous tumor cells within anextensive mucin pool.Using the American Joint Committee on Cancer (AJCC)staging for gallbladder cancer, the final diagnosis was gall-bladder cancer stage IVB (pT4NxM1). However the patientdied of disease 48 days after the operation.This case report raised the following interesting issues.First, since 15% of ovarian cancers are secondary and 7e15%

Uterine sarcoma part III—Targeted therapy: The Taiwan Association of Gynecology (TAG) systematic review

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Advanced endocervical adenocarcinoma metastatic to the ovary presenting as primary ovarian cancer

Dear Editor,Cervical squamous cell carcinoma (SCC) and adenocarcinomamay involve the ovary. Although it is not difficult to diagnose inmost cases, on very rare occasions the presentation may showsymptoms related to an ovarian mass, with the cervical cancerbeing undetected, especially endocervical adenocarcinoma [1,2].This is important because the challenge of diagnosing primaryendocervical adenocarcinoma occurs especially in women whoshow no symptoms, and have a grossly normal cervix and anegative Pap smear [3]. The spread of cervical malignancy (bothSCC and adenocarcinoma) is often through lymphatic drainage ordirect invasion [4]; except some reports show that endocervicaladenocarcinoma carries a higher risk of ovarian metastases thanSCC of the cervix [5]. There is an apparent difference in the treat-ment strategy for advanced cervical cancers and ovarian cancers[6,7]. Therefore, making an accurate diagnosis before planningtherapy is of paramount importance. The following is a case reportof advanced cervical adenocarcinoma metastatic to the ovarymimicking primary ovarian cancer.A 54-year-old menopausal woman (G3P3) visited the emer-gency room due to acute sudden onset of abdominal pain afterseveral weeks of abdominal fullness. Her past medical history wasunremarkable. She did not have any Pap smears since the birth ofherlastchild(28yearspreviously).Physicalexaminationrevealedaprotuberant and tense abdomen, but the cervix was essentiallynormal. Transvaginal ultrasound revealed a 15 cm complex cysticmass lesion located at the right adnexal area accompanied withmassive ascites, but the uterus and the left ovary seemed to benormal.Computedtomographyidentifiedandconfirmed theabovefinding (Fig. 1). Serum tumor markers, including CA 125, CA 199,and CEA were 286.0 U/mL, 209.0 U/mL, and 226.0 ng/mL, respec-tively. Other investigations, including hematological andbiochemical tests, a chest X-ray, and upper and lower gastrointes-tinal (GI) tract evaluations were within normal limits.Under the diagnosis of ovarian malignancy, the patient under-went a laparotomy. During surgery, a right ovarian cystic complexmass with a mucinous component (Fig. 2) accompanied withmassive ascites (7000 mL) and peritoneal carcinomatosis wasfound. The immediate frozen pathology report favored a diagnosisof adenocarcinoma-mucinous type. Therefore, the patient under-went an optimal debulking surgery, including total hysterectomy(Fig. 3), bilateral salpingo-oophorectomy, infracolic omentectomyand retroperitoneal lymph node sampling, and multiple biopsies.However, the final pathologic report was primary uterine endo-cervical adenocarcinoma.Pathologic features included hyperchromatic dysplasia of themucinous glandular cells of the uterine endocervix; the mucinoustumor occupied the whole layer of the endocervix and extended tothe lower segment of the uterine body. Other sections of the rightovary, appendix, omentum, abdominal wall, and mesentery allshowed tumor metastases with floating mucinous tumor cellswithin an extensive mucin pool.The patient was treated with adjuvant systemic chemotherapy(8 cycles of topotecan [Hycamtin Injection, GlaxoSmithKline, San

Brain Metastasis of Ovarian Epithelial Carcinoma

Ovarian cancer is the seventh most common cancer and the fifth leading cause of cancer death in the world, after lung and bronchial cancers, and breast, colorectal and pancreatic cancers. Ovarian cancer causes more deaths than any other cancer of the female reproductive system. Brain metastases resulting from primary ovarian cancer are uncommon [1]. However, recent studies have suggested an increased incidence of brain metastases in patients with primary ovarian cancer [2–4]. Surgery, irradiation, and chemotherapy can all be used to prolong patient survival, although the prognosis remains poor [4]. McMeekin et al [5] studied the survival of 104 ovarian cancer patients with metastatic brain disease following a combination of surgery, irradiation, and/or chemotherapy. Their report indicated a median survival of 6 months for these patients, regardless of the treatment modality [5]. Some investigators have reported relatively successful efforts in prolonging the life of these metastatic patients. Gabriele et al reported a mean survival of 17 months in a group of 23 ovarian cancer patients with solitary brain metastases treated with surgery and radiotherapy [6]. The survival of ovarian cancer patients with metastatic disease treated with irradiation was around 2 years [5,7]. Systemic chemotherapy has also proven effective for the treatment of brain metastases [1,7]. A 58-year-old Taiwanese woman was originally referred to our gynecologic oncology clinic for treatment of an ovarian epithelial carcinoma in May 2005. She presented with increased abdominal girth and poor appetite. Her preoperative serum CA-125 level was 4,491 U/mL. She underwent laparotomy with optimal debulking surgery (en bloc total abdominal hysterectomy and bilateral salpingo-oophorectomy, and cavitron ultrasonic surgical aspirator debulking from the peritoneal surfaces). The pathology revealed a poorly differentiated stage IIIC ovarian serous adenocarcinoma (Figure 1) with metastasis to the omentum, appendix, paraortic and pelvic lymph nodes. The patient subsequently received six courses of paclitaxel and carboplatin, commencing in June 2005. Her CA-125 level fell to 12.7 U/mL in November 2005, and complete clinical and surgical remission was achieved. Another 12 courses of maintenance paclitaxel chemotherapy were administered thereafter, and her serum CA-125 level ranged from 12 to 15 U/mL until November 2006. In May 2007, she presented with intermittent headaches, nausea, cognitive dysfunction, gait ataxia, and urinary and fecal incontinence, resulting in consultation with a neurologist. There was no weakness, syncope or seizure history. A brain magnetic resonance imaging examination revealed a 5-cm mass in the left frontal lobe with a cystic component and irregular thick wall, and perifocal edema with compression of the left lateral ventricle, resulting in midline structures shifting to the right side (Figure 2). No other apparent lesions were noted in the abdomen, chest or spine. An elevated serum CA-125 level, as high BRAIN METASTASIS OF OVARIAN EPITHELIAL CARCINOMA

Comparison of single-port and three-port laparoscopic salpingectomy in the management for tubal pregnancy

Background: To compare the short‐term outcome of patients undergoing single‐port laparoscopic salpingectomy (SP‐LS) and conventional three‐port laparoscopic salpingectomy (C‐LS). Methods: A retrospective evaluation of 112 patients with tubal pregnancies treated by one surgeon at a single teaching hospital. Among these, 47 patients were treated with SP‐LS and the remaining 65 were treated with C‐LS. Results: The characteristics of patients were similar in both groups. There were no statistically significant differences in operative time, estimated blood loss, intraoperative and immediate postoperative complications, and length of hospital stay between both groups. Time to bowel recanalization (6.2 ± 1.0 vs. 7.2 ± 1.4 h, p < 0.05) and postoperative visual analog scale for pain scores (3.0 ± 0.5 vs. 3.6 ± 0.6, p < 0.005) were significantly lower in the SP‐LS group compared with those in the C‐LS group. Conclusion: Our study demonstrated the feasibility to use the single‐port laparoscopic salpingectomy in the management of women with tubal pregnancy, which showed the similar or better outcome compared with the use of conventional three‐port laparoscopic salpingectomy.