Ming-Shien Yen

Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy.

OBJECTIVE On the basis of outcome data from concurrent chemoradiotherapy (CCRT) for locally advanced cervical squamous cell carcinoma, the authors developed a nomogram for predicting survival outcome. STUDY DESIGN Two hundred fifty-one eligible patients with International Federation of Gynecology and Obstetrics stage IIB-IVA squamous cell carcinoma of the uterine cervix who underwent CCRT were included for the construction of the nomogram. Predictor variables included age, serum squamous cell carcinoma antigen, tumor size, parametrium invasion, hydronephrosis, bladder/rectum invasion, and lymph node metastases. Internal validation of the nomogram was performed. RESULTS A nomogram for predicting the 5 year overall survival for these patients was constructed on the basis of a Cox regression model from 7 parameters. The concordance index was 0.69. CONCLUSION This nomogram is a predictive tool, upon external validation, that can be used to counsel patients in predicting outcomes. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.

Impact of pregnancy on primary dysmenorrhea

Objective: Because it has been observed that dysmenorrhea can improve after childbirth, this investigation was intended to quantify the impact of both gestational length and mode of delivery on primary dysmenorrhea. Methods: This is an 8‐year prospective observational study. Patients with a history of dysmenorrhea who later gave birth were evaluated for improvement on the severity of dysmenorrhea, with use of visual analogue scale (VAS), and Likert‐type scale. Result: Final analysis involved 3694 patients. Women who had spontaneous delivery would have significantly more improvement than women with cesarean delivery per VAS (term delivery, 51 vs. 33, P < 0.001; preterm delivery, 17 vs. 10, P < 0.001). For first delivery, patients in the spontaneous delivery subgroup were the most likely to have improvement in severity of dysmenorrhea. For second delivery, only patients in the spontaneous delivery subgroup had statistically significant improvement. Conclusion: Both length of gestation and mode of delivery have an impact on primary dysmenorrhea. The most significant improvement occurred after the first delivery.

Natural Progression of Menstrual Pain in Nulliparous Women at Reproductive Age: An Observational Study

Background: Menstrual pain can be alleviated after childbirth. The purpose of this observational study was to evaluate the natural progression of menstrual pain among nulliparous women at their reproductive age. Methods: A questionnaire‐based study of perimenopausal women with a history of primary dysmenorrhea was performed. The study subjects were recruited between July 1, 2001 and June 30, 2005. Severity of menstrual pain was graded using a multidimensional scoring system. Results: A total of 247 nulliparous women with primary dysmenorrhea were enrolled, and of these, 218 patients were eligible for analysis. Patients who had more frequent intercourse (p = 0.016), fewer associated systemic symptoms (p = 0.028), and use of oral contraceptive pills (p = 0.039) tended to have a higher chance of an improvement in dysmen‐orrhea after age 40. Multidimensional scoring distribution over chronologic age revealed that patients had significantly improved menstrual pain after 40 years of age. Conclusion: For nulliparous women with primary dysmenorrhea, the severity of menstrual pain decreased significantly after age 40. More studies are needed to explore this phenomenon from a biochemical or molecular basis.

Importance of delivered cycles and nomogram for intraperitoneal chemotherapy in ovarian cancer

OBJECTIVE Intraperitoneal (IP) chemotherapy has gained enthusiasm in the treatment of ovarian cancer. Despite having a better survival advantage than intravenous (IV) chemotherapy, IP chemotherapy still poses significant morbidity and complications. Identifying the subset of patients who could best benefit from IP chemotherapy, and those who would least benefit from this treatment, thus avoiding potential complications, is critical. METHODS Between January 2001 and December 2007, 367 patients with stage III epithelial ovarian cancer underwent randomized trial for IP/IV chemotherapy were recruited to construct a nomogram, which is a graphical representation of Cox proportional hazards model adopting six weighted risk factors including age, CA125, IP/IV delivery, stage, histology, and upper abdominal metastases. The nomogram was internally validated for discrimination and calibration. The concordance index was used for quantifying the predictive ability of overall survival with bootstrapping to correct for bias. RESULTS The cycles of completed IP chemotherapy had an impact on overall survival (> or =5 vs. < or =4 cycles, P=0.02). A nomogram for predicting median survival and 5-year survival probability was constructed with a concordance index of 0.72. Upper abdominal tumor metastases (P<0.001) and colon resection (P=0.02) predicted increased chances for early discontinuation of IP chemotherapy. CONCLUSIONS At least five IP cycles are needed to achieve better survival. Nomogram can help to identify the subset of patients who can least benefit from IP chemotherapy, thus avoiding potential IP complications and help to facilitate discussion between patient and physician, risk stratification, and help to guide clinical care.

Combined Diverticulectomy and Anti-Incontinence Surgery for Patients with Urethral Diverticulum and Stress Urinary Incontinence: Is Anti-Incontinence Surgery Really Necessary?

OBJECTIVE Urethral diverticulum has been identified in 0.6-6% of women and is diagnosed most frequently in the third to fifth decades. Combined diverticulectomy and anti-incontinence surgery are usually undertaken for patients with urethral diverticulum who present with symptoms of stress urinary incontinence. However, this approach may not always be necessary. CASE REPORT We report two cases with urethral diverticulum and stress urinary incontinence successfully treated with diverticulectomy only. CONCLUSION This clinical approach could avoid the potential complications of anti-incontinence surgery.

Treatment of Primary Deep Dyspareunia with Laparoscopic Uterosacral Nerve Ablation Procedure: A Pilot Study

Background: This pilot study was undertaken to evaluate the effect of laparoscopic uterosacral nerve ablation (LUNA) for treatment of primary deep dyspareunia. Methods: Between July 2002 and June 2003, 12 consecutive patients diagnosed with primary deep dyspareunia were treated with the LUNA procedure. The evaluation scoring system included the Hospital Anxiety and Depression Scale and the revised Sabbatsberg Sexual Rating Scale, done at baseline and 3, 6, and 12 months after LUNA. Results: At the initial 3‐month follow‐up period, 3 patients were very satisfied with their treatment, 5 were satisfied, 2 uncertain, 1 dissatisfied, and 1 very dissatisfied. The corresponding figures at the 12‐month follow‐up visit were 2, 4, 4, 1, and 1, respectively. Overall, 8 (66.7%) patients in this trial were very satisfied or satisfied at the initial postoperative evaluation and 6 of them (50.0%) remained satisfied at the final evaluation. Conclusion: Over half of the study patients felt satisfied with the results of treatment with LUNA. Further prospective controlled clinical trials are mandatory to validate its effectiveness.

Physiology and potential application of NKT cells: a minireview.

CD1d-restricted T (NKT) cells are potent regulators of autoimmunity, tumor immunity, and transplantation-related immunity. NKT cells are a subset of innate lymphocytes that recognize endogenous or exogenous glycolipids in the context of CD1d molecules. Recent progress in the research of NKT cells has proved that NKT cells function as a bridge between innate and adaptive immunity in anticancer immunity. Furthermore, NKT cells also function as a bridge to tolerance or rejection of grafts in organ transplantation. Harnessing the function of NKT cells, and trying to put it into clinical application in the treatment of autoimmune disease, anticancer cell immunotherapy, and organ transplantation are the dreams of immunologists. This minireview will focus on the physiology of NKT cells and potential clinical application.

Investigation of Serum CA125 Distribution Pattern in Uterine Leiomyoma and Uterine Leiomyosarcoma

Purpose Most comparisons between uterine leiomyoma and uterine leiomyosarcoma were based on postoperative pathological or molecular analyses. Very few reports have been investigated preoperative differentiation between uterine leiomyoma and uterine leiomyosarcoma. Methods Between January 1990 and December 2003, 42 consecutive patients with uterine leiomyosarcoma treated at the index hospitals were analyzed. Meanwhile, 84 patients with uterine leiomyomas were used as controls. The author evaluated diagnostic performance of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma using receiver operating characteristic (ROC) curves. Data presentations were categorized into premenopausal group and postmenopausal group. Diagnostic efficiency was calculated as the sensitivity multiplied by the specificity. Results Values of preoperative serum CA125 were significantly higher in the uterine leiomyosarcoma group than those in the uterine leiomyoma group. There was significant overlapping of preoperative serum CA125 between uterine leiomyoma group and early stage uterine leiomyosarcoma. For both premenopausal and postmenopausal group, there was significant difference in the distribution of preoperative serum CA125 in early stage and advanced stage uterine leiomyosarcoma. The optimal cutoff values of serum CA125 for the premenopausal group and postmenopausal group was 162 U/mL and 75 U/mL, respectively. Conclusion These findings demonstrated that preoperative serum CA125 had a potential role in the differential diagnosis between early stage and advanced stage uterine leiomyosarcoma. Further investigation with larger sample size at adequate power is necessary to verify the current study.

Correlation between Ascites and Serum CA125 in Patients with Ovarian Cancer

Objective Ovarian cancer is the second most common gynecologic cancer and remains the major cause of death for gynecologic malignancy. The aim of this study was to evaluate the role of preoperative serum CA-125 level and volume of ascites for prognostic prediction. Methods This study was a prospective non-randomized study. 110 patients with advanced stage epithelial ovarian cancer after primary debulking surgery between 1995 and 2000 were enrolled. CA-125 blood samples were collected preoperatively for each recruited patient and assayed using radioimmunoassay method. Volume of ascites was recorded intraoperatively. Ascites was defined if the peritoneal fluid was more than 100 cc. Results. A total of 96 patients were eligible for evaluation. The 5-year overall survival in the ascites group was 46% versus 34% in the no-ascites group (P=0.245, log-rank test). However, patients had poorer overall survival if ascites volume was more than 500 ml (P=0.044, log-rank test). The preoperative serum CA-125 was significantly higher in the ascites group (Mean±SEM, 1107±134 U/ml) than in the no-ascites group (Mean±SEM, 351±103 U/ml). Cox regression analysis showed extent of residual disease and serum CA-125 were two independent prognostic factors. Conclusion Ascites was a common finding in patients with advanced ovarian cancer. Pre-operative serum CA-125 was statistically significant higher in the ascites group than that in the no-ascites group. Univariate analysis showed poorer prognosis when ascites was more than 500 ml, but the role failed to exist after multivariate analysis.

Successful treatment of deep dyspareunia and primary dysmenorrhea with laparoscopic uterosacral nerve ablation (LUNA) procedure.

Deep dyspareunia, often described as pain resulting from pelvic thrusting during sexual intercourse, is relatively common and has many causes. To date, feasible surgical interventions for deep dyspareunia are very rare. The two procedures which have been mentioned in the literature for the treatment of deep dyspareunia were laparoscopic uterosacral ligament ablation (LUNA) and uterine ventrosuspension. We report the case of a young female patient, aged 32, gravida 3, parity 2, presenting with deep dyspareunia and primary dysmenorrhea for 4 years. She had both subjective and objective improvements for dyspareunia and primary dysmenorrhea following LUNA operation. Further large-scaled randomized controlled trial is mandatory to verify the surgical effect of LUNA operation for patients with deep dyspareunia.