Taejong Song

Prognosis of ovarian clear cell carcinoma compared to other histological subtypes: A meta-analysis

OBJECTIVEnTo compare the survival outcome between clear cell carcinoma (CCC) and other histological subtypes in epithelial ovarian carcinoma (EOC).nnnMETHODSnFrom January 1974 to February 2011, we identified a total of 31,800 (CCC; 2152, non-CCC; 29648) patients from 12 studies meeting the inclusion criteria.nnnRESULTSnHeterogeneity tests demonstrated significant between-study variation (I(2)=92.1%) with no significant difference in hazard ratio (HR) for death between CCC and non-CCC (HR; 1.16, 95% CI; 0.85-1.57, random-effects model). Comparing the HR based on stage I+II, and stage III+IV, between CCC and non-CCC, showed that CCC patients had a higher hazard rate for death than those with non-CCC of the ovary (stage I+II; HR; 1.17, 95% CI; 1.01-1.36, stage III+IV; HR; 1.65, 95% CI; 1.52-1.79). In a comparison of CCC and serous EOC, advanced stage (III and IV) CCC only showed a poorer hazard rate for death than serous EOC (HR; 1.71, 95% CI; 1.57-1.86).nnnCONCLUSIONnThis analysis suggests that ovarian CCC patients had poorer prognosis than those with other histological subtypes of EOC, especially in advanced EOC stages. Different treatment strategies may be needed for patients with ovarian CCC.

Single-port access (SPA) laparoscopic surgery in gynecology: a surgeon's experience with an initial 200 cases

OBJECTIVEnTo report our initial two hundred single-port access (SPA) gynecologic surgeries and present the perioperative outcomes.nnnSTUDY DESIGNnThis is a prospective single-center study (Canadian Task Force classification II-2). Two hundred selected patients with gynecological disease were recruited for the study from May 2008 through December 2009 at Samsung Medical Center.nnnRESULTSnTwo hundred patients underwent SPA gynecological surgery (105 a total hysterectomy; 11 a subtotal hysterectomy; 43 an oophorectomy; 31 an ovarian cystectomy; 5 a salpingectomy; 2 a myomectomy; 3 adhesiolysis only). The median age and body mass index were 45.5 and 22.9 kg/m(2), respectively. SPA surgery was successfully completed in 187 patients, without the need for ancillary ports (93.5%). Two cases required a conventional multiport, and nine cases needed one additional port. Two patients were converted to a laparotomy. One intra- and five post-operative complications occurred. The complication rate was 3.2% (6/187). The median operative time was 120 min (54-250) for a total hysterectomy, 180 (150-345) for a subtotal hysterectomy, 60 (27-245) for an oophorectomy, 105 (50-185) for a cystectomy, and 60 (30-115) for a salpingectomy.nnnCONCLUSIONnSingle-port surgery was safe and feasible for gynecological indications. Further study of single-port surgery is required to determine whether it has significant benefits compared to conventional techniques.

Prognostic value of pre-treatment circulating monocyte count in patients with cervical cancer: Comparison with SCC-Ag level

OBJECTIVEnHigher level of circulating monocyte has been reported to be related with higher cancer incidence and mortality. We investigated the role of pre-treatment circulating monocyte count for cancer specific survival in cervical squamous cell carcinoma patients comparing with pre-treatment squamous cell carcinoma-related antigen (SCC-Ag) level.nnnMETHODSnWe retrospectively enrolled patients with squamous cell carcinoma of the cervix (FIGO stage IB to IVA) who had complete blood cell counts with differential cell count and serum SCC-Ag level within 2 weeks before starting initial treatment and were treated at Samsung Medical Center, Seoul, Korea, from 1996 to 2007.nnnRESULTSnThe 788 patients in our study group had a median follow-up of 53.4 months and a five-year survival rate of 87.8%. The median value for pre-treatment circulating monocyte count was 349/μl (21-1463), and the median concentration of SCC-Ag was 1.6 ng/ml (0.1-362.0). In multivariable analysis, the pre-treatment circulating monocyte count was an independent prognostic factor for progression-free survival and overall survival in locally advanced disease (P=0.007 and P=0.038) but not in case of SCC-Ag for overall survival. The combined index of monocyte count and SCC-Ag level could enhance the prognostic value of SCC-Ag alone in patients with locally advanced cervical squamous cell carcinoma.nnnCONCLUSIONSnA higher pre-treatment circulating monocyte count is independently associated with poor prognosis in patients with locally advanced cervical squamous cell carcinoma. The pre-treatment circulating monocyte count may be considered as an adjunctive biomarker with SCC-Ag.

Accuracy of frozen section diagnosis of borderline ovarian tumors

OBJECTIVEnTo determine the correlation between the diagnosis of borderline ovarian tumors (BOTs) by frozen section and permanent histology analyses.nnnMETHODSnThree hundred fifty-four pathology reports with diagnoses of BOTs by frozen section or permanent histology analysis at a single institution between 1995 and 2010 were evaluated with a review of the literature. Frozen section and permanent histology analyses were compared. Multivariate regression analysis was used to assess the influence of clinicopathological parameters on the likelihood of underdiagnosis.nnnRESULTSnThe overall accuracy, i.e., agreement between frozen section and permanent histology diagnoses, was observed in 228 of 354 (64.4%) cases, yielding a sensitivity of 72.6%, a positive predictive value of 85.1%, underdiagnosis in 108 cases (30.5%), and overdiagnosis in 18 cases (5.1%). Based on multivariate analysis, mucinous histology (OR, 1.48; P=0.022) was the only significant predictor for underdiagnosis by frozen section. A comprehensive search of the literature identified 46 studies investigating the accuracy of frozen section analysis of BOTs. The data of 7 of 46 studies that met the criteria for inclusion and the data of the current study were pooled. The overall accuracy was 67.1% (741/1104), yielding a sensitivity of 82.1%, a positive predictive value of 78.7%, underdiagnosis in 222 cases (20.1%), and overdiagnosis in 141 cases (12.8%).nnnCONCLUSIONSnFrozen section analysis of BOTs has low accuracy, sensitivity, and positive predictive value, and underdiagnosis and overdiagnosis are frequent. Therefore, surgical decision-making for BOTs based on frozen section diagnosis should be done carefully, especially in tumors with mucinous histology.

Single Port Access Laparoscopic-Assisted Vaginal Hysterectomy for Large Uterus Weighing Exceeding 500 Grams: Technique and Initial Report

STUDY OBJECTIVEnTo present our initial experience with single-port access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH) in a large uterus weighing in excess of 500 g.nnnDESIGNnA prospective single-center study (Canadian Task Force classification III).nnnSETTINGnUniversity hospitalnnnPATIENTSnFifteen patients with an extirpated uterine weight of more than 500 g were enrolled from May 2008 to September 2009.nnnINTERVENTIONSnSPA-LAVH.nnnMEASUREMENTS AND MAIN RESULTSnThere were 11 cases with uterine myomas and 4 cases of adenomyosis. All patients had symptoms related to these diagnoses including menorrhagia, dysmenorrhea, and pelvic pressure symptoms such as urinary frequency. The median and range are used to describe data not distributed normally. The median operation time, weight of the uterus, and estimated blood loss were 125 minutes (80 to 236 minutes), 690 g (503 to 1260 g), and 500 mL (150 to 1000 mL), respectively. There was a significant linear correlation between the operation time and the extirpated uterine weight (p<.002). Thirteen procedures were successfully performed with SPA-LAVH. The SPA procedure failed in 2 cases: 1 (uterine weight, 732 g) required 1 ancillary 5-mm port to manipulate with a myoma screw, and in the other we inserted 1 additional 15-mm port to use for a laparoscopic morcellator. There were no umbilical complications, additional procedures, or surgical complications.nnnCONCLUSIONnThe SPA-LAVH procedure for a large uterus weighing in excess of 500 g was as safe and effective as the conventional LAVH. Additional experience and continued investigation are warranted.

Oncologic and reproductive outcomes of cystectomy compared with oophorectomy as a treatment for borderline ovarian tumours

BACKGROUNDnThe aim of this study was to compare the oncologic and reproductive outcomes of patients with borderline ovarian tumours (BOTs) who were treated with cystectomy or unilateral salpingo-oophorectomy (USO).nnnMETHODSnThe medical records of patients with BOTs who were treated between 1997 and 2009 were reviewed retrospectively. The recurrence rates were compared between the USO and cystectomy groups. The reproductive outcomes were assessed by telephone interviews.nnnRESULTSnPatients with BOTs underwent a USO (n= 117) or cystectomy (n= 38). There were 12 patients who had recurrences: 1 patient had an invasive recurrence and 11 had borderline recurrences. The recurrence rate in the USO group (6.0%) was lower than in the cystectomy group (13.2%); however, this difference was not statistically significant (P= 0.110). All of the patients with recurrences were successfully treated with surgery and there was no clinical evidence of disease. Of the 116 patients contacted by telephone, 113 (97.4%) resumed menstruation following the surgery, and 45 of the 52 patients (86.5%) who attempted to conceive had successful pregnancies. USO (89.2%), like cystectomy (85.7%), resulted in excellent pregnancy rates for patients with BOTs.nnnCONCLUSIONSnA USO is an appropriate treatment for women with BOTs who wish to preserve fertility. However, a cystectomy is a satisfactory fertility-sparing therapy when a cystectomy is the only surgical option.

What is the learning curve for single-port access laparoscopic-assisted vaginal hysterectomy?

OBJECTIVEnSingle-port access (SPA) surgery is a rapidly advancing technique in laparoscopic surgery. Currently, there is limited evidence on the learning curve and complications of performing SPA laparoscopic-assisted vaginal hysterectomies (LAVHs).nnnSTUDY DESIGNnOne hundred patients who initially planned to undergo a SPA-LAVH for benign indications between May 2008 and October 2009 were enrolled. All operative data were prospectively collected. Patients were arranged in order based on the date of surgery and the outcomes were compared between quartiles (cases 1-25, 26-50, 51-75, and 76-100). Proficiency was defined as the point at which the slope of the curve becomes less steep for operative time. Plateau was defined as the point at which the slope is zero. A comparison of the data on a quartile was performed. Locally weighted regression generated smoothed lines that represent operative time over the sequence of the operations.nnnRESULTSnMost SPA-LAVHs were successful, but additional ports were needed in 5 patients because of pelvic adhesions (n=3) and large uterine size (n=2). There were 3 cases with post-operative complications (hemorrhage, 1; vesicovaginal fistula, 1; and cuff abscess, 1), who were managed without sequelae. Without increased operative morbidities, the operative time decreased from a median of 133.0 min (interquartile range, 107.5-162.5 min) in the first quartile to a median of 100.0 min (interquartile range, 85.0-117.5 min) for the last quartile (p=0.011). The proficiency and plateau were determined after approximately 25 and 75 cases, respectively.nnnCONCLUSIONSnThe SPA-LAVH was safe, effective, and reproducible after training, and with the current technique, had a low rate of complications.

A review of the technique and complications from 2,012 cases of laparoscopically assisted vaginal hysterectomy at a single institution.

Aims:u2002 To present our experience of modified laparoscopically assisted vaginal hysterectomy (LAVH) and to evaluate the surgical outcomes and complications.

Pediatric borderline ovarian tumors: a retrospective analysis

BACKGROUND/PURPOSEnBorderline ovarian tumors (BOTs) are uncommon in the pediatric population, and there have been limited studies that have included a small number of patients. In present study, we evaluated the clinical outcomes and the rates of recurrence of pediatric BOTs with larger sample size than those in previous studies.nnnMETHODSnA retrospective chart review was performed on 29 patients who were treated for histopathologically confirmed BOTs at our institution between January 1997 and December 2009.nnnRESULTSnTwenty-nine patients (median age, 18 years) had a large-sized tumor (median, 19.8 cm). Abdominal pain was the most common symptom, seen in 82.8% of the patients, followed by abdominal distension. The permanent section histology revealed 25 mucinous (86.2%) and 4 serous type tumors (13.8%). There was considerable discordance between the permanent and frozen sections (rate of concordance, 55.1%). Disease stage was IA in 26 patients (89.7%) and stage IC in the other 3 patients (10.3%). All patients underwent fertility-preserving surgery. Overall, 4 patients (13.8%) experienced a clinically suspicious recurrence requiring surgery. In 2 cases, the suspected recurrences were found to be other benign ovarian tumors. In one case that was initially treated with left ovarian cystectomy for a mucinous BOT, subsequent left salpingo-oophorectomy confirmed recurrence of a mucinous BOT at 16-month follow-up. The last case was a newly developed primary ovarian mucinous carcinoma with no evidence of recurrence of a previous mucinous BOT at 26-month follow-up.nnnCONCLUSIONSnThis study shows that BOTs in pediatric populations can be successfully treated conservatively to preserve fertility with no apparent increased risk of morbidity or mortality compared with those of more radical surgical options.

Prognostic significance of DNA ploidy in stage I endometrial cancer

OBJECTIVEnTo improve the outcome for patients with endometrial cancer, a more accurate prognostic assessment is needed. The current study was undertaken to determine the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with stage I endometrial cancer and to verify if ploidy is able to identify high-risk cases among the apparent low-risk patients, defined as stage (IA), grade (1 or 2), and histologic type (endometrioid).nnnMETHODSnThis was a retrospective study. DNA ploidy was evaluated from tumor samples in 217 patients with stage I endometrial cancer who underwent definitive surgery as the first treatment between 2003 and 2009. Ploidy and other classic parameters were analyzed in relation to the length of recurrence-free survival.nnnRESULTSnAmong the 217 evaluated patients, 184 (84.8%) had diploid tumors and 33 (15.2%) had aneuploid tumors. There were 12 recurrences during the median follow-up intervals of 42.7 months. Stage, grade, histologic type, lymphovascular space invasion (LVSI), and ploidy were significantly correlated with recurrence-free interval by univariate Cox analysis. Based on multivariate Cox analysis, ploidy was an independent prognostic factor, with a hazard ratio of 4.5 (95% confidence interval [CI], 1.3-15.3; P=0.017) adjusted for stage, grade, histologic type, and LVSI. In low-risk patients (n=156), the recurrence rate was 2.1% for diploid tumors and 12.5% for aneuploid tumors (P=0.038).nnnCONCLUSIONSnDNA aneuploidy is an independent prognostic factor in patients with endometrial cancer and can identify high-risk patients among those considered low-risk with stage I endometrial cancer.