Seok-Cheol Choi

Current status of gynecological cancer in China

The aim of this review is to examine the current status of gynecological cancer in China focusing on epidemiological data. Epidemiological data on gynecological cancer in China is sparse. Therefore, most of the data were estimated via extrapolation based on a few available datasets. Cervical cancer is relatively rare and the incidence and mortality rate are largely decreasing. However, in young women, the incidence and mortality rates are increasing. The overall and age-specific incidence rates of cervical cancer appear to be varied according to geographical areas. The overall prevalence rate of human papillomavirus (HPV) in China is similar with other eastern Asian countries, but the age-specific HPV prevalence showed sustained high HPV prevalence rates in elderly women. There is not yet an established national program for cervical cancer prevention. The incidence rate of corpus and ovarian cancers in China slightly increased between 2000 and 2005, but is still lower than Japan or Korea. There is no reliable, national-level data on mortality rates of corpus and ovarian cancer in China. Breast cancer is one of the most rapidly increasing cancers in China. The increase was sharper in young women than in elderly women. Both increased risk and change of population size/structure contributed to the increase of breast cancer.

Randomized Clinical Trial of Weekly vs. Triweekly Cisplatin-Based Chemotherapy Concurrent With Radiotherapy in the Treatment of Locally Advanced Cervical Cancer

PURPOSE To compare compliance, toxicity, and outcome of weekly and triweekly cisplatin administration concurrent with radiotherapy in locally advanced cervical cancer. METHODS AND MATERIALS In this open-label, randomized trial, 104 patients with histologically proven Stage IIB-IVA cervical cancer were randomly assigned by a computer-generated procedure to weekly (weekly cisplatin 40 mg/m(2), six cycles) and triweekly (cisplatin 75 mg/m(2) every 3 weeks, three cycles) chemotherapy arms during concurrent radiotherapy. The difference of compliance and the toxicity profiles between the two arms were investigated, and the overall survival rate was analyzed after 5 years. RESULTS All patients tolerated both treatments very well, with a high completion rate of scheduled chemotherapy cycles. There was no statistically significant difference in compliance between the two arms (86.3% in the weekly arm, 92.5% in the triweekly arm, p > 0.05). Grade 3-4 neutropenia was more frequent in the weekly arm (39.2%) than in the triweekly arm (22.6%) (p = 0.03). The overall 5-year survival rate was significantly higher in the triweekly arm (88.7%) than in the weekly arm (66.5%) (hazard ratio 0.375; 95% confidence interval 0.154-0.914; p = 0.03). CONCLUSIONS Triweekly cisplatin 75-mg/m(2) chemotherapy concurrent with radiotherapy is more effective and feasible than the conventional weekly cisplatin 40-mg/m(2) regimen and may be a strong candidate for the optimal cisplatin dose and dosing schedule in the treatment of locally advanced cervical cancer.

Is adjuvant chemoradiotherapy overtreatment in cervical cancer patients with intermediate risk factors

PURPOSE To determine whether adjuvant chemoradiotherapy (CRT) improves the outcome of cervical cancer patients with intermediate risk factors. METHODS AND MATERIALS Between January 2000 and June 2006, the medical records of 735 patients who had undergone radical surgery for Stage IB-IIA cervical cancer were reviewed retrospectively. Of the 735 patients, 172 with two or more intermediate risk factors (i.e., lymphovascular space involvement, deep stromal invasion, and tumor size≥2 cm) were grouped as follows according to the adjuvant treatment received: 34 patients, no further treatment; 49 patients, RT; and 89 patients, CRT. The significance of the clinical parameters and recurrence-free survival of each group were analyzed. RESULTS Of the 172 patients with any of the intermediate risk factors, 137 (79.6%) had two or more intermediate risk factors. Of the 172 patients, 12 developed recurrences (6.4%)->(7.0%), with 6 in the pelvis and 6 in distant sites. All 12 recurrences occurred in those who had two or more intermediate risk factors (sensitivity, 100%); however, only six recurrences were detected in patients who met the Gynecologic Oncology Group criteria for the intermediate-risk group (sensitivity, 50%; Z test, p<.05). A statistically significant difference was found in the 3-year recurrence-free survival rate among the no further treatment, RT, and CRT groups (67.5%, 90.5%, and 97.5%, respectively; p<.05). The incidence of Grade 3-4 hematologic and gastrointestinal toxicities was not significantly different statistically between the RT and CRT groups (6.1% and 13.4%, respectively; p > .05). CONCLUSION Postoperative adjuvant CRT can improve the outcome of cervical cancer patients with intermediate risk factors, with low increase in toxicity.

Detection of Recurrence by 18F-FDG PET in Patients with Endometrial Cancer Showing No Evidence of Disease

This study assessed the feasibility of F-18-fluorodeoxyglucose positron-emission tomography (18F-FDG PET) in the post-therapy surveillance for patients with endometrial cancer showing no evidence of disease (NED). From April 1997 to June 2007, 127 patients with endometrial cancer showing NED were performed 18F-FDG PET scan. The feasibility of 18F-FDG PET for the early detection of recurrence in patients with endometrial cancer was evaluated retrospectively. Of the 127 patients, 32 patients showed positive lesions on 18F-FDG PET scan. Nineteen (19/127 cases, 15%) of them were confirmed to have a recurrence clinically or histologically. The sensitivity, specificity and positive and negative predictive value of 18F-FDG PET for detecting recurrences in patients with endometrial cancer were 100%, 88%, 59% and 100%, respectively. In conclusion, 18F-FDG PET may be a useful method for the post-therapy surveillance in patients with endometrial cancer.

Characteristics of thyroid incidentalomas detected by pre-treatment [18F]FDG PET or PET/CT in patients with cervical cancer

Objective Considering the increased use of [18F]FDG PET or PET/CT, the clinical significance of thyroid incidentalomas is the subject of controversy. The aim of this study was to determine the incidence of malignancies associated with thyroid incidentalomas detected by pre-treatment PET or PET/CT in patients with cervical cancer. Methods We retrospectively reviewed the medical records of patients with cervical cancer who had thyroid incidentalomas detected by pre-treatment PET or PET/CT and were treated at our institute between January 2001 and December 2009. Results Of 327 patients who underwent pre-treatment PET or PET/CT, 33 patients had thyroid incidentalomas (10.1%) and 4 patients were diagnosed with thyroid malignancies by percutaneous needle aspiration (PCNA) or surgery. To put it concretely, of 33 patients with thyroid incidentaloma, 16 patients had a diffuse uptake and 17 patients had a focal uptake. Four of 17 patients with focal uptake were diagnosed with thyroid malignancies (23.5%). One patient with a focal uptake had an atypical cell based on PCNA, but did not undergo additional studies. The mean SUVmax of thyroid malignancies did not differ from that of benign thyroid diseases. Conclusion Thyroid incidentalomas are frequently detected by pre-treatment PET or PET/CT in patients with cervical cancer. Focal uptake on PET or PET/CT has a high risk of thyroid cancer.

Efficacy of Fibrin Sealant in Reducing Hemorrhage after a Loop Electrosurgical Excision Procedure

Background/Aims: We examined the association of fibrin sealant use with post-operative hemorrhage in patients who underwent a loop electrosurgical excision procedure (LEEP). Methods: We retrospectively collected clinicopathologic data of 344 patients who underwent LEEP at our institute between 2007 and 2009. We defined hemorrhage which occurred between 1 and 30 days after LEEP and required electrocautery to achieve hemostasis as severe secondary hemorrhage (SSH). We determined whether or not the use of fibrin sealant during LEEP was associated with a decreased occurrence of SSH. In addition, we examined the associations of other clinicopathologic variables with SSH and fibrin sealant use. Results: SSH occurred in 6 of 200 patients (3%) with fibrin sealant and in 12 of 144 patients (8%) without fibrin sealant. Based on univariate analysis, the use of fibrin sealant was associated with SSH (p = 0.028). However, age, surgeons and pathologic diagnosis were not associated with SSH. Based on multivariate analysis, the use of fibrin sealant was associated with less SSH (p = 0.033, OR = 0.328, 95% CI 0.117–0.917). Conclusion: Fibrin sealant use reduces the incidence of severe post-operative hemorrhage after LEEP.

Risk of metastatic ovarian involvement in nongynecologic malignancies.

Objective The objectives were to evaluate the risk of malignant adnexal tumors in women with nongynecologic malignancies and to identify variables associated with the risk of malignant adnexal tumors. Methods The eligibility criteria included the diagnosis of a nongynecologic malignancy and adnexal tumors, which were resected or subjected to biopsy at our institute between 1999 and 2010. The risk of malignant adnexal tumors was assessed by dividing the number of patients with metastatic tumors to the adnexa or primary adnexal cancers by the total number of patients. The association of clinicopathologic variables with the risk of malignant adnexal tumors was evaluated using the Fisher exact test and binary logistic regression analysis. In patients with metastatic tumors to the adnexa, the association of clinicopathologic variables with overall survival after adnexal surgery was examined using the log-rank test. Results In 166 patients with adnexal tumors, 41 benign tumors, 113 metastatic tumors to the adnexa, and 12 primary adnexal cancers were diagnosed. Age older than 46 years, a tumor type associated with a high risk for malignant adnexal tumors, and bilateral tumors significantly increased the risk of malignant adnexal tumors. The overall survival of the patients with stomach cancer was significantly worse than the patients with colorectal or breast cancers. Conclusion One hundred twenty-five of the 166 patients with nongynecologic malignancies who had adnexal tumors managed surgically were shown to have malignant tumors, and most of the tumors were metastatic from primary sites. The risk of malignant adnexal tumors was associated with age, nongynecologic malignancy, and bilaterality.

Inadvertent potential risk of neoadjuvant chemotherapy in cervical cancer

Randomized clinical trials comparing neoadjuvant chemotherapy (NAC) followed by surgery with initial surgery in cervical cancer reported conflicting results. We provided a hypothesis explaining the different outcomes between trials. NAC was reported to make a lymph node metastasis smaller. Smaller tumors are hard to detect and potentially undetected at pathologic examination. Undetected metastasis would lead to an erroneous exclusion of high-risk patients from adjuvant therapy. An erroneous exclusion would lead to a recurrence. This harmful concealing effect of NAC could negate the potentially beneficial effect of NAC and the conflicting results of trials could be the result of the balance between harmful and beneficial effect of NAC. Because the concealing effect of NAC can be reversed by adjuvant therapy, trials comparing NAC followed by surgery with initial surgery in which all patients in both arms received adjuvant therapy reported positive result. However, in a trial in which only patients with lymph node or parametrial involvements received adjuvant therapy, the concealing effect was not reversed by adjuvant therapy and reported negative result. Our empirical data showed that patients who underwent NAC followed by surgery and were classified as low-risk based on pathologic parameters had unexpectedly high recurrence rate. To evaluate our hypothesis, a trial comparing a conventional pathologic examination with a more sophisticated examination such as ultrastaging in patients with cervical cancer who received NAC followed by surgery would be necessary. If our hypothesis is proven, trials considering the concealing effect of NAC should be performed to accurately evaluate the role of NAC in cervical cancer.

Clinicopathologic factors for central recurrence in patients with locally advanced bulky cervical cancer.

OBJECTIVE Locally advanced bulky cervical cancer (LABCC) is characterized by poor local control. The objective of this study was to identify the clinicopathologic variables associated with one-year central-only recurrence, which will serve as criteria for adjuvant hysterectomy after radiation (AHR) in patients with LABCC. STUDY DESIGN Between January 2000 and August 2007, we retrospectively evaluated outcomes in 225 patients with LABCC who were initially treated with radiation or chemoradiation. RESULTS Among the 225 patients with LABCC, there were 41 recurrences within one year after treatment (8 central-only and 33 pelvis and/or distant site recurrences). Age, stage, and treatment type were not associated with the one-year central-only recurrences, but tumor size ≥8cm had a statistically significant association based on multivariate analysis (OR, 5.39; 95% CI, 1.15-25.31; p=0.03). The combination of non-squamous cell (non-SCC) type and tumor size ≥8cm had a significantly higher rate of recurrence within one year (OR, 43.0; 95% CI, 4.78-386.68; p<0.01). CONCLUSIONS Of patients with LABCC, those with non-SCC tumors ≥8cm in size were at high risk for early central-only recurrence after cisplatin-based chemoradiation, and represent the subset of patients for whom AHR is beneficial.

Schwannoma of the clitoris: A case report

Schwannomas arise from schwann cells in the peripheral nerve sheath, without involving the nerve fibers. Schwannomas are benign, slow-growing tumors that infrequently recur and rarely undergo malignant change. Also schwannomas of the female genitalia are considered extremely rare. We report a case of schwannoma of the clitoris. A 76-year-old woman without neurofi bromatosis presented with a 2.0 × 1.7 cm, painless mass of the clitoris. Simple surgical excision of the mass was undertaken, and fi nal pathology revealed schwannoma of the clitoris. No evidence of local recurrence was noted after 1 year of follow-up.