Kuan-Chin Wang

The Risk of Epithelial Ovarian Cancer of Women With Endometriosis May be Varied Greatly if Diagnostic Criteria Are Different: A Nationwide Population-Based Cohort Study

AbstractThis article aims to test the hypothesis that the risk of epithelial ovarian cancer (EOC) in women with endometriosis might be changed by enrolling different population.A nationwide 14-year historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan and the Registry for Catastrophic Illness Patients was conducted. A total of 239,385 women aged between 20 and 51 years, with at least 1 gynecologic visit after 2000, were analyzed. Cases included women with a diagnosed endometriosis, which was established along a spectrum from at least 1 medical record of endometriosis (recalled endometriosis) to tissue-proved ovarian endometriosis (n = X). Controls included women without any diagnosis of endometriosis (n = 239,385 – X). We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CI) to determine the risk of EOC in patients.The EOC incidence rates (IRs, per 10,000 person-years) of women with endometriosis ranged from 1.90 in women with recalled endometriosis to 18.70 in women with tissue-proved ovarian endometrioma, compared with those women without any diagnosis of endometriosis (0.77–0.89), contributing to crude HRs ranging from 2.59 (95% CI, 2.09–3.21; P < 0.001) to 24.04 (95% CI, 17.48–33.05; P < 0.001). After adjustment for pelvic inflammatory disease, infertility, Charlson co-morbidity index, and age, adjusted HRs were ranged from the lowest of 1.90 (95% CI, 1.51–2.37; P < 0.001) in recalled endometriosis to the highest of 18.57 (95% CI, 13.37–25.79; P < 0.001) in tissue-proved ovarian endometrioma, which was inversely related to the prevalence rate of endometriosis (from the highest of 30.80% in recalled endometriosis to the lowest of 1.54% in tissue-proved ovarian endometrioma).The risk of EOC in women with endometriosis varied greatly by different criteria used. Women with endometriosis might have a more apparently higher risk than those reported by systematic review and meta-analysis.

Robertsonian translocations: An overview of a 30-year experience in a single tertiary medical center in Taiwan

Background: Advanced maternal age (AMA) is the most frequent indication for amniocentesis in predicting balanced reciprocal translocations, and abnormal ultrasound findings are indications in predicting unbalanced reciprocal translocations; however, to date, no studies have focused on Robertsonian translocations. Methods: A retrospective review was conducted on 16,749 pregnant women who underwent midtrimester amniocentesis between January 1981 and December 2010. Robertsonian translocations were identified in 39 cases. Results: The percentage of Robertsonian translocations in all amniocentesis cases was 0.23% (39/16,749); 31 were balanced and eight were unbalanced. De novo abnormality occurred in 17 cases, or in 43.6% of all Robertsonian translocations. The two major indications for amniocentesis with a diagnosis of Robertsonian translocations were AMA (41.0%, n = 16) and a parent with abnormal karyotypes (18.0%, n = 7). The highest percentage of Robertsonian translocations was found in parents with abnormal karyotypes (2.8%, 7/252), but neither of the indications were clearly superior for detecting de novo Robertsonian translocations. Conclusion: Although AMA is an indication for amniocentesis in approximately two‐fifths of cases with Robertsonian translocations, the indication of parent with abnormal karyotypes was more likely to lead to the detection of non‐de novo Robertsonian translocations, suggesting that parents with abnormal karyotypes need careful prenatal consultation.

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.

Reproductive performance of severely symptomatic women with uterine adenomyoma who wanted preservation of the uterus and underwent combined surgical-medical treatment.

OBJECTIVE To assess the factors associated with future pregnancy and successful delivery in women who were treated for uterine adenomyoma with combination (surgical-medical) therapy using ultramini- or mini-laparotomy conservative surgery and gonadotropin-releasing hormone agonist. MATERIALS AND METHODS One hundred and two women were evaluated. Items for analysis included: age, body mass index, and conception history; clinical symptoms of dysmenorrhea and menorrhagia; tumor location and preoperative serum level of cancer antigen 125 (CA125); the intraoperative findings of the weight of the removed tumor, and the uterine cavity opening. RESULTS After excluding those patients using contraception or searching for an assisted reproductive technique, a total of 56 women were enrolled for analysis. Twenty-three (41.1%) women had 27 clinical pregnancies after 3 years of follow-up; 15 went on to deliver a healthy live-born child; two delivered preterm but healthy babies; seven had elective abortions; four had spontaneous abortions; and one had an ectopic pregnancy. The women who had a successful delivery during the 3-year follow-up after treatment tended to be younger, with a lower body mass index, lower baseline analgesic usage score, and lower preoperative serum level of CA125, be nulliparous, and with an adenoma in an anterior location. The linear regression model showed that age and baseline analgesic usage score were independent predictors of successful delivery and accounted for 56.5% of the total variance related to successful delivery. CONCLUSION Age was an important factor associated with future successful delivery, therefore, caution should be taken in considering the maintenance of future fertility in older women treated with surgical-medical therapy.

Development of a chip-based multiplexed immunoassay using liposomal nanovesicles and its application in the detection of pathogens causing female lower genital tract infections.

OBJECTIVE Cervicovaginitis is a highly prevalent disease that is a burden on healthcare globally. Immediate and adequate treatment can eradicate the infection and block subsequent complications. The feasibility of achip-based multiplexed immunoassay using liposomal nanovesicles was tested. MATERIALS AND METHODS A multiplexed immunoassay chip containing five antibodies for five pathogens (Chlamydia trachomatis, Escherichia coli, Neisseria gonorrhoeae, Streptococcus agalactiae, and Candida albicans) was established and tested. Four patients with spiking of candidiasis were enrolled. The difference between positive and negative readings was evaluated using the paired Student t test. RESULTS The detection threshold of Candida in this microarray was 100,000 CFU/mL in a vaginal sample, and the time required for the whole procedure was 3 hours. The testing of the four patients showed 100% for both sensitivity and specificity. CONCLUSION This microarray chip was a rapid, easy, inexpensive and sensitive tool for detecting female lower genital tract Candida infection in a one-time vaginal sampling process, although the data on the four other pathogens were still unavailable. A larger population study is encouraged to test the validity of this multiplexed immunoassay chip.

Endometriosis Might Be Inversely Associated with Developing Chronic Kidney Disease: A Population-Based Cohort Study in Taiwan

This study was conducted to determine the risk of chronic kidney disease (CKD) among women with endometriosis in Taiwan. We conducted a retrospective cohort study using the National Health Insurance Research Database of Taiwan. A total of 27,973 women with a diagnosis of endometriosis and 27,973 multivariable-matched controls (1:1) from 2000 to 2010 were selected. Cox regression and computed hazard ratios (HR) with 95% confidence intervals (95% CI) were used to determine the risk of CKD among women with endometriosis. The incidence rates (IR, per 10,000 person-years) of CKD among women with and without endometriosis were 4.64 and 7.01, respectively, with a significantly decreased risk of CKD (crude HR 0.65, 95% CI 0.53–0.81; adjusted HR 0.69, 95% CI 0.56–0.86) among women with endometriosis. The IR of CKD progressively increased with age, but the trend of lower CKD risk among women with endometriosis was consistent. However, the lower risk of CKD in women with endometriosis was no longer statistically significant after adjusting for menopausal status (adjusted HR 0.85, 95% CI 0.65–1.10). The results suggest that endometriosis is inversely associated with CKD, but this effect was mediated by menopause. The possible mechanism of this association is worthy of further evaluation.

An 11-year experience with ovarian surgery during pregnancy.

Background: The management of ovarian tumors during pregnancy can be challenging because of the risk of fetal wastage and the possibility of surgery‐related complications, or a delayed diagnosis of a possibly lethal disease or malignancy. The aim of this study was to study the characteristics and outcomes of pregnant women undergoing surgical intervention for ovarian tumors during pregnancy. Methods: We reviewed the data of 102 pregnant women who underwent ovarian surgery between 2000 and 2010 at Taipei Veterans General Hospital, Taiwan. Data subject to analysis included gestational age at the time of surgery, complications, surgical and pathological findings, and the outcome of pregnancy. Results: Fifty‐two women who underwent surgery were excluded, whether by cesarean section, during the postpartum period or during simultaneous abortion surgery. Ultimately, the data of 50 patients were analyzed. Almost all patients (n = 46, 92%) were asymptomatic and underwent elective surgery. Frequently, this surgery was done in the second trimester (n = 35, 70%). We determined that teratoma (26%), mucinous cystadenomas (20%), and endometriomas (16%) were the three most common pathological findings. Nonspecific ovarian tumors were common (28%), including seven corpus luteum cysts, six simple cysts, and one paratubal cyst. Two women were diagnosed with malignant ovarian tumors, but both were metastatic and the primary site was the colon. Ten women underwent laparoscopic surgery. General anesthesia was used in four patients, and all underwent emergency exploratory laparotomy. There was no surgery‐related complication or instance of preterm labor. Conclusion: In our study cohort, surgical intervention during pregnancy was safe, since neither surgical approach, such as exploratory laparotomy or laparoscopic surgery, nor anesthesia methods, for example general anesthesia or spinal anesthesia showed negative impact on the pregnancy outcomes. Reported cases of malignant ovarian tumor are still rare, thus, the possibility of metastatic tumor should be considered first.

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%

Squamous cell carcinoma occurring in the pelvis after total hysterectomy and bilateral salpingo-oophorectomy for an ovarian mature teratoma with malignant transformation.

Department of Obstetrics and Gynecology, Cardinal Tien Hospital-Hsintien, New Taipei City, Taiwan Department of Obstetrics and Gynecology, Fu Jen Catholic University, New Taipei City, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan e Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan h Institute of Hospital and Health Care Administration, National Yang-Ming University School of Medicine, Taipei, Taiwan Department of Nursing, Oriental Institute of Technology, New Taipei City, Taiwan j Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan k Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan

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.