Suk-Joon Chang

Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: A meta-analysis

OBJECTIVE To quantify the impact of complete cytoreduction to no gross residual disease on overall survival among patients with advanced-stage ovarian cancer treated during the platinum-taxane era. METHODS PubMed and Cochrane Library databases were searched for all articles on primary cytoreductive surgery for advanced-stage ovarian cancer published from 1/1996 to 7/2011. A total of 18 relevant studies (13,257 patients) were identified for analysis. Simple and multiple linear regression analyses, with weighted correlation calculations, were used to assess the effect on median survival time of clinical and treatment-related factors. RESULTS The mean weighted median overall survival time for all cohorts was 44.4 months (range, 27.6-66.9 months). Simple linear regression analysis revealed that residual disease, stage IV disease, and use of intraperitoneal chemotherapy were significantly associated with median survival time. After controlling for other factors on multiple linear regression analysis, each 10% increase in the proportion of patients undergoing complete cytoreduction to no gross residual disease was associated with a significant and independent 2.3-month increase (95%CI = 0.6-4.0, p = 0.011) in cohort median survival compared to a 1.8-month increase (95%CI = 0.6-3.0, p = 0.004) in cohort median survival for optimal cytoreduction (residual disease≤1cm). Each 10% increase in the proportion of patients receiving intraperitoneal chemotherapy was associated with a significant and independent 3.9-month increase (95%CI = 1.1-6.8, p=0.008) in median cohort survival time. CONCLUSIONS For advanced-stage ovarian cancer treated during the platinum-taxane era, the proportions of patients left with no gross residual disease and receiving intraperitoneal chemotherapy are independently significant factors associated with the most favorable cohort survival time.

Clinical characteristics of struma ovarii.

OBJECTIVE To evaluate the clinical characteristics of struma ovarii. METHODS Twenty-five cases of struma ovarii were reviewed retrospectively from June 1994 to April 2007. The presenting clinical, radiologic, and pathologic features of the patients were reviewed. RESULTS The mean age of the patients in this study was 45.3 years. The majority was of premenopausal status. Sixteen patients had clinical symptoms such as low abdominal pain, palpable abdominal mass and vaginal bleeding. Although one patient had an abnormal thyroid function test, the laboratory findings normalized after operative treatment. CA-125 levels were elevated in 6 cases. Diagnosis by preoperative imaging studies were 8 dermoid cysts, while only 3 cases were diagnosed as struma ovarii. There were 4 cases of malignant struma ovarii, and no patients with recurrent disease. CONCLUSION Struma ovarii is a rare tumor. The presented clinical, laboratory and radiological findings of patients are very diverse. The diagnosis was confirmed by pathologic findings. The treatment of benign struma ovarii is surgical resection only. The cases of malignant struma ovarii may need adjuvant treatment, but recurrence is uncommon.

Role of aggressive surgical cytoreduction in advanced ovarian cancer

Ovarian cancer is the eighth most frequent cancer in women and is the most lethal gynecologic malignancy worldwide. The majority of ovarian cancer patients are newly diagnosed presenting with advanced-stage disease. Primary cytoreductive surgery and adjuvant taxane- and platinum-based combination chemotherapy are the standard treatment for advanced ovarian cancer. A number of studies have consistently shown that successful cytoreductive surgery and the resultant minimal residual disease are significantly associated with survival in patients with this disease. Much has been written and even more debated regarding the competing perspectives of biology of ovarian cancer versus the value of aggressive surgical resection. This review will focus on the current evidences and outcomes supporting the positive impact of aggressive surgical effort on survival in the primary management of ovarian cancer.

Prognostic significance of the micropapillary pattern in patients with serous borderline ovarian tumors

Background. The impact of micropapillary histology on survival in patients with serous borderline ovarian tumors is not established. The purpose of this study was to evaluate the significance and influence of micropapillary pattern on clinical outcome of patients with serous borderline ovarian tumors. Methods. Eighty‐five patients who underwent surgery and were diagnosed with serous borderline ovarian tumors were retrospectively studied. Among these patients, 18 patients showed micropapillary pattern on histologic examination, while the remaining 67 patients did not. The significance of the presence of micropapillary pattern and relationship with various clinicopathologic findings and progression‐free survival were evaluated by statistical analysis. Results. No differences with regard to age, parity, body mass index, pretreatment CA‐125 level, tumor size, bilaterality, and the duration of follow‐up were observed between the two groups, but there was a significant difference in terms of FIGO stage (p<0.001), invasive implants (p = 0.004), performing lymphadenectomy (p = 0.009), operation time (p = 0.003), estimated blood loss (p<0.001), residual disease>1 cm (p = 0.001), adjuvant chemotherapy (p<0.001), and the length of hospital stay (p = 0.013). Progression‐free survival was found to be significantly decreased in patients with invasive implants (HR, 5.06; p = 0.025) and micropapillary pattern (HR, 4.20; p = 0.056) on multivariate analysis. Conclusions. Micropapillary serous borderline ovarian tumors were associated with a more aggressive clinical course compared with typical serous borderline ovarian tumor. The presence of invasive implants and micropapillary pattern were significant prognostic factors in patients with serous borderline ovarian tumors.

Long-term outcomes after fertility-sparing laparoscopic radical trachelectomy in young women with early-stage cervical cancer: An Asan Gynecologic Cancer Group (AGCG) study

To evaluate the long‐term outcomes and risk factors for recurrence after fertility‐sparing laparoscopic radical trachelectomy (LRT) in young women with early‐stage cervical cancer.

A model for prediction of parametrial involvement and feasibility of less radical resection of parametrium in patients with FIGO stage IB1 cervical cancer.

OBJECTIVE The objective of this study was to evaluate the potential risk factors associated with parametrial invasion and to identify preoperatively a subgroup of patients at low risk for parametrial involvement who could be appropriate candidates for less radical surgery in FIGO stage IB1 cervical cancer. METHODS We retrospectively reviewed the medical records of 317 FIGO stage IB1 cervical cancer patients undergoing class III radical hysterectomy and bilateral pelvic lymphadenectomy. Clinocopathologic factors associated with parametrial invasion were analyzed and the risk criteria predicting parametrial involvement were calculated using a logistic regression model. RESULTS Of 317 patients, 17 patients (5.4%) had parametrial involvement. Tumor size >3 cm (OR, 3.80; [95% CI, 1.19-12.06]; p=0.02) and pelvic lymph node metastasis (OR, 3.02; [95% CI, 1.04-8.79]; p=0.04) were independent pathologic factors for parametrial invasion on multivariate analysis. Significant preoperative factors associated with parametrial involvement were tumor size >3 cm (OR, 4.29; [95% CI, 1.43-12.89]; p<0.01) and serum SCC Ag level >1.40 ng/mL (OR, 3.27; [95% CI, 1.11-9.69]; p=0.03). We identified 185 low-risk (tumor size ≤ 3 cm and SCC ≤ 1.4 ng/mL) and 132 high-risk (tumor size>3 cm and/or SCC>1.4 ng/mL) patients. The rates of parametrial involvement in low- and high-risk patients were 1.1% and 11.4%, respectively (p<0.01). CONCLUSIONS In this dataset, a model using tumor size and SCC Ag level is highly predictive of parametrial involvement in patients with stage IB1 cervical cancer and may identify candidates for less radical parametrial resection.

Prognostic significance of systematic lymphadenectomy as part of primary debulking surgery in patients with advanced ovarian cancer.

OBJECTIVE The objective of this study was to evaluate the impact of systematic pelvic and para-aortic lymphadenectomy on survival in patients with advanced ovarian cancer. METHODS We retrospectively analyzed the data of 189 consecutive patients with FIGO stage IIIC ovarian cancer between 2000 and 2011, who underwent primary cytoreductive surgery followed by platinum- and taxane-based chemotherapy. All patients were classified into two groups - patients who underwent systematic pelvic and para-aortic lymphadenectomy and those who did not. Progression-free (PFS) and overall survival (OS) times were analyzed using Kaplan-Meier method and Cox proportional hazards model. RESULTS Patients who underwent systematic lymphadenectomy had significantly improved PFS (22 versus 9 months, p<0.01) and OS (66 versus 40 months, p<0.01). In patients with no gross residual disease (NGR) or residual disease 0.1-1cm (GR-1), the median OS time of those who had lymphadenectomy was significantly longer than those who did not (86 versus 46 months, p=0.02). However, in patients with residual disease >1cm (GR-B), there was no significant difference in OS according to lymphadenectomy (39 versus 40 months, p=0.50). Among patients with NGR, the median OS time of those who underwent systematic lymphadenectomy was significantly longer than those who did not undergo lymphadenectomy (not yet reached [>96] and 56 months, p<0.01). No significant difference of OS between patients with and without lymphadenectomy was observed in the subgroup of patients with GR-1 (50 versus 38 months, p=0.44). The performance of lymphadenectomy was a statistically significant and independent predictor of improved OS in addition to the status of residual disease and the performance of radical cytoreductive procedures (hazard ratio, 0.34; [95% CI, 0.23-0.52]; p<0.01). CONCLUSIONS Systematic lymphadenectomy may have a therapeutic value and be significantly associated with improved survival in stage IIIC ovarian cancer patients with grossly no visible residual disease.

Comparison of laparoscopic versus conventional open surgical staging procedure for endometrial cancer

OBJECTIVE The aim of this study was to compare the surgical outcomes of laparoscopic surgery and conventional laparotomy for endometrial cancer. METHODS A total of 104 consecutive patients were non-randomly assigned to either laparoscopic surgery or laparotomy. All patients underwent comprehensive surgical staging procedures including total hysterectomy, bilateral salpingo-oophorectomy, and pelvic/para-aortic lymphadenectomy. The safety, morbidity, and survival rates of the two groups were compared, and the data was retrospectively analyzed. RESULTS Thirty-four patients received laparoscopic surgery and 70 underwent laparotomy. Operation time for the laparoscopic procedure was 227.0+/-28.8 minutes, which showed significant difference from the 208.1+/-46.4 minutes (p=0.032) of the laparotomy group. The estimated blood loss of patients undergoing laparoscopic surgery was 230.3+/-92.4 mL. This was significantly less than that of the laparotomy group (301.9+/-156.3 mL, p=0.015). The laparoscopic group had an average of 20.8 pelvic and 9.1 para-aortic nodes retrieved, as compared to 17.2 pelvic and 8.5 para-aortic nodes retrieved in the laparotomy group. There was no significant difference (p=0.062, p=0.554). The mean hospitalization duration was significantly greater in the laparotomy group than the laparoscopic group (23.3 and 16.4 days, p<0.001). The incidence of postoperative complications was 15.7% and 11.8% in the laparotomy and laparoscopic groups respectively. No statistically significant difference was found between the two groups in the survival rate. CONCLUSION Laparoscopic surgical staging operation is a safe and effective therapeutic procedure for management of endometrial cancer with an acceptable morbidity compared to the laparotomic approach, and is characterized by far less blood loss and shorter postoperative hospitalization.

Para-aortic lymphadenectomy improves survival in patients with intermediate to high-risk endometrial carcinoma

Objective. Surgical staging of endometrial carcinoma is practiced to identify the true extent of disease. The impact of para‐aortic lymphadenectomy (PALD) on survival is unproven. The purpose of this study was to determine if a staging procedure that includes PALD is associated with improved survival in endometrial carcinoma patients who had been surgically staged. Design. Retrospective review of patients’ records. Setting. Ajou University Hospital, a tertiary care hospital in South Korea. Population. One hundred and sixty patients with endometrial carcinoma. Methods. We retrospectively analyzed a total of 160 FIGO stage I–III endometrial carcinoma patients without grossly metastatic para‐aortic lymph nodes, who underwent surgery between 1994 and 2007. Exclusion criteria included presurgical radiation, stage IV disease and sarcomas. Two groups were identified: patients who underwent pelvic lymphadenectomy (PLD) and PALD (n = 85) versus those who underwent PLD alone (n = 75). Survival was analyzed using Kaplan–Meier method and Cox proportional hazards model. Main outcome measures. Disease‐free and overall survival. Results. Overall, patients who underwent PALD demonstrated improved 5‐year disease‐free survival (81.0 vs 91.2%) and overall survival (85.8 vs 96.2%) compared to those who underwent PLD alone (p = 0.019 and p = 0.039, respectively). After multivariate analysis, patients’ age (p = 0.028), FIGO stage (p<0.001) and lymphadenectomy (p = 0.014) were independent prognostic factors. The type of lymphadenectomy did not affect survival of low‐risk patients. In intermediate to high‐risk patients, PALD improved disease‐free survival and showed a trend toward improvement of overall survival. Conclusion. These data demonstrate that PALD has a potentially therapeutic benefit on survival in surgically staged patients with intermediate to high‐risk endometrial carcinoma.

Practice guidelines for the early detection of cervical cancer in Korea: Korean Society of Gynecologic Oncology and the Korean Society for Cytopathology 2012 edition

The consensus guideline development committee of Korean Society of Gynecologic Oncology was reconvened in March 2012. The committee consisted of 36 experts representing 12 university hospitals and professional organizations. The objective of this committee was to develop standardized guidelines for cervical cancer screening tests for Korean women and to distribute these guidelines to every clinician, eventually improving the quality of medical care. Since the establishment of the consensus guideline development committee, evidence-based guidelines have either been developed de novo considering specific Korean situations or by adaptation of preexisting consensus guidelines from other countries. Recommendations for cervical cancer screening tests, management of atypical squamous and glandular cells, and management of low-grade and high-grade squamous intraepithelial lesions were developed. Additionally, recommendations for human papillomavirus DNA testing and recommendations for adolescent and pregnant women with abnormal cervical screening test results were also included.