Informed consent forms for gynecologic cancer surgery: recommendations from the Korean Society of Gynecologic Oncology

The sociomedical environment is changing. In the traditional physician-patient relationship, the physician was authoritative and the patient was obedient. The contractual relationship featured patient consent to the physician’s decision. Today, the physician must explain fully the planned medical treatment, and any alternative, to the patient, who has the right to choose her treatment after considering the benefits and side-effects. The Korean Society of Gynecologic Oncology thus decided to standardize the surgical consent forms to meet the legal requirements of modern medicine, improve patient understanding of the surgical details, and protect medical staff from legal disputes. To determine the format and content, subcommittees for each cancer type collected and reviewed all relevant articles and the current consent forms of domestic medical institutions. After several meetings, 16 basic items to be included for each type of gynecologic cancer were selected. Also, to help patients understand the surgical details, figures were included. The revised forms were legally reviewed in terms of the appropriateness of the format and content. We also developed English versions to provide adequate information for foreign patients. We hope that these efforts will promote trust between patients and physicians, and contribute to effective treatment by laying a foundation of mutual respect.

Comparative Survival Outcome of Robot-Assisted Staging Surgery Using Three Robotic Arms versus Open Surgery for Endometrial Cancer

Purpose@#There is lack of data on direct comparison of survival outcomes between open surgery and robot-assisted staging surgery (RSS) using three robotic arms for endometrial cancer. The purpose of this study was to compare the overall survival (OS) and disease-free survival (DFS) between open surgery and RSS using three robotic arms for endometrial cancer. @*Materials and Methods@#Consecutive women with endometrial cancer who underwent surgery between May 2006 and May 2018 were identified. Robotic procedures were performed using the da Vinci robotic system, and the robotic approach consisted of three robotic arms including a camera arm. Propensity score matching, as well as univariate and multivariate Cox regression of OS and DFS were performed according to clinicopathologic data and surgical method. @*Results@#The study cohort included 423 unselected patients with endometrial cancer, of whom 218 underwent open surgery and 205 underwent RSS using three robotic arms. Propensity score-matched cohorts of 146 women in each surgical group showed no significant differences in survival: 5-year OS of 91% vs. 92% and DFS of 86% vs. 89% in the open and robotic cohorts, respectively (hazard ratio, 1.02; 95% confidence interval, 0.82–1.67). In the univariate analysis with OS as the endpoint, surgical method, age, stage, type II histology, grade, and lymph node metastasis were independently associated with survival. Surgical stage, grade, and type II histology were found to be significant independent predictors for OS in the multivariate analysis. @*Conclusion@#RSS using three robotic arms and laparotomy for endometrial carcinoma had comparable survival outcomes.

In vitro wear behavior between enamel cusp and three aesthetic restorative materials: Zirconia, porcelain, and composite resin

PURPOSE: The aim of this study was to identify the effects of three aesthetic restorative materials on the wear between tooth and restoration by a pin-on-disk manner. MATERIALS AND METHODS: Six aesthetic restorative materials were used to prepare disk specimens for wear test, which were Lava Zirconia as zirconia group, Vintage MP and Cerabien ZR as veneering porcelain group, Gradia Direct microhybrid composite containing prepolymerized fillers, Filtek Z250 microhybrid composite containing zirconia glass and colloidal silica particles, and Filtek Z350 nanocomposite as composite resin group. Vertical loss of the worn cusp, change of the surface roughness of the restoration materials, and the surface topography were investigated after wear test under 9.8-N contact load. RESULTS: The porcelain groups (Vintage MP and Cerabien ZR) caused the largest vertical loss of teeth when compared with those of the composite resin and zirconia groups, and Filtek Z250 microhybrid composite results in the second-largest vertical loss of teeth. The surface of Filtek Z350 nanocomposite was deeply worn out, but visible wear on the surface of the zirconia and Gradia Direct microhybrid composite was not observed. When the zirconia surface was roughened by sand-blasting, vertical loss of teeth considerably increased when compared with that in the case of fine polished zirconia. CONCLUSION: It was identified that microhybrid composite resin containing a prepolymerized filler and zirconia with reduced surface roughness by polishing were the most desirable restorative materials among the tested materials to prevent the two-body wear between aesthetic restorative material and tooth.

HPV-Related Retroperitoneal Squamous Cell Carcinoma of Unknown Primary: A Case Report / Journal of the Korean Cancer Association, 대한암학회지

A 56-year-old female was referred to our hospital due to a mass measuring 5 cm in size in the left pelvic cavity, which was found incidentally during a health examination by ultrasonography. Exploratory laparotomy was performed and the mass was located at the left retroperitoneal parametrium without invasion of the uterus and ovary. The pathology report confirmed squamous cell carcinoma. Even after further studies, we did not find any other primary lesion. Human papillomavirus (HPV) DNA chip test (HPV 9G DNA Membrane Kit, Biometrixtechnology Inc.) showed that the surgical specimen was positive for HPV 18. She received adjuvant chemotherapy and would receive radiation therapy for the possibility of occult gynecologic cancer. Retroperitoneal squamous cell carcinoma of unknown primary is extremely rare and little is known about it. It is reported that HPV may be associated with the disease. Hence, the result of HPV test could have an impact on finding a suspicious primary lesion and treatment modality in this case.

Laparoscopic transabdominal cervical cerclage: Case report of a woman without exocervix at 11 weeks gestation

Cervical incompetence is characterized by painless dilatation of the incompetent cervix and results in miscarriages and preterm delivery during second trimester. We report a 25-year-old patient, gravid 2, para 1, at 11 weeks' gestation with the diagnosis of cervical incompetence, in whom transvaginal cerclage was not technically possible and laparoscopic cervical cerclage was performed successfully. There were no operative or immediate postoperative complications. A healthy infant was delivered at 35 weeks by cesarean section. Laparoscopic cervical cerclage during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence and eliminates the need for open laparotomy.

Clinical Validation of AdvanSure GenoBlot Assay as Primary Screening and Test of Cure for Human Papillomavirus Infection

BACKGROUND: Clinical specificity and sensitivity are essential factors in the adoption of a human papillomavirus (HPV) test as a primary screening tool and test of cure after treatment of cervical cancer and precancerous lesions (High-Risk-Lesion). Using histologically-confirmed High-Risk-Lesion-patient specimens with postoperative follow-ups, we performed clinical validation of the AdvanSure GenoBlot Assay (GenoBlot; LG Life Sciences, Korea). METHODS: The study population included 100 cases with High-Risk-Lesion, 96 with high-risk genotype positive and cervical intraepithelial neoplasia (CIN) 1 or better, and 39 with HR-negative and better than CIN 1. Forty-eight High-Risk-Lesion cases received follow-up HPV exams after surgery. For validation as a test of cure, 48 preoperative specimens (PreOP) and 78 postoperative specimens (PostOP) from 48 subjects were separately analyzed. The results of HPV DNA chip tests (HPVDNAChip; BioMedLab Co., Korea) and sequencing were cross-compared. RESULTS: The concordance rates for each genotype between HPVDNAChip and GenoBlot were between 96.3-100%. The accuracy of HPVDNAChip and GenoBlot was 87.9% and 96.6%, respectively. Genotype-based specificity for High-Risk-Lesion detection was higher than 87% for both assays; genotype 16 showed the highest sensitivity. In the PostOP group, the positive rates for HPVDNAChip and GenoBlot were 30.8% and 47.4%, respectively. CONCLUSIONS: GenoBlot showed a higher positive rate than HPVDNAChip for each genotype, with concordance rate and accuracy being similar to previous reports. As a test of cure, GenoBlot performed better than the HPVDNAChip.

Clinical significance of tumor volume and lymph node involvement assessed by MRI in stage IIB cervical cancer patients treated with concurrent chemoradiation therapy / 부인종양

OBJECTIVE: The purpose of this study was to evaluate the prognostic significance of tumor volume assessed by pretreatment MRI in stage IIB cervical cancer patients with concurrent chemoradiation therapy. METHODS: A retrospective chart review was performed on seventy five patients with cervical cancer who were treated with concurrent weekly cisplatin (40 mg/m2) and radiotherapy between January 2000 and April 2007. Potential prognostic factors were age, chemotherapy numbers, histology, tumor diameter and volume, lymph node (LN) involvement and pretreatment squamous cell carcinoma antigen (SCC-Ag) levels. RESULTS: The median follow-up time was 55 months (range, 8 to 104 months). The median tumor size and volume (range) were 4.5 cm (2 to 10) and 33.1 mL (4.2 to 392.7), respectively. Pelvic LN enlargement rate was 58.7%. Para-aortic LN enlargement rate was 14.7%. Using multivariate analysis, a tumor volume (>33 mL, p=0.025), pelvic LN enlargement (p=0.044) revealed a significantly unfavorable outcome on overall survival. PFS was influenced by tumor histology (p<0.001), pelvic LN enlargement (p=0.015) and pretreatment SCC-Ag levels (p=0.018). We found that 22 (29.3%) patients had recurrences and 14 (18.7%) patients died of disease. The 5-year overall survival rate was 80.6% (standard error, 4.9%) and 5-year PFS rate was 71.3% (standard error, 5.3%). CONCLUSION: Tumor volume and pelvic LN involvement showed possibility to predict overall survival in patient with stage IIB cervical cancer. Optimal tumor volume and pelvic LN assessment by pretreatment MRI might be helpful to predict treatment outcome.

A case of metastatic ovarian carcinoma originated from small cell lung carcinoma / 대한산부인과학회지

Approximately 5% to 22% of malignant tumors involving the ovary are metastases, and the carcinomas of the gastrointestinal tract are responsible for 81% to 88% of these cases. A lung cancer, one of the most common malignancies and well known to metastasize widely, rarely metastasize to the ovary. There has been no report on small cell lung cancer metastasized to the ovary in Korea. Recently, we experienced a case of metastatic ovarian cancer originated from small cell lung cancer in 46-year-old Korean woman with which is confirmed with the immunohistochemistry. Herein we report the case with brief review of literature.

Expression of the p16(INK4a) and Ki-67 in relation to the grade of cervical intraepithelial neoplasia and high-risk human papillomavirus infection / 부인종양

OBJECTIVE: The purposes of this study were to evaluate the expression of p16(INK4a) (referred as to p16) and Ki-67 in cervical intraepithelial neoplasia (CIN), and the correlation between high-risk human papillomavirus (HPV) infection and the above biomarkers. METHODS: We analyzed 31 patients who were diagnosed with CIN at Kwandong University Myongji Hospital from October 2006 to September 2007. CIN specimens (CIN1, 12; CIN2, 6; CIN3, 13) were obtained by colposcopy-directed biopsy (CDB) or loop electrical excision procedure (LEEP). The expressions of p16 and Ki-67 were evaluated by immunohistochemical methods with antibodies to p16 and Ki67. The immunohistochemical staining results were classified into four grades: 0, 1, 2 and 3. HPV genotyping or Hybrid Capture-II test was used to detect high-risk HPV. RESULTS: The expression of p16 (p<0.001) and Ki-67 (p=0.003) were positively associated with CIN grade. p16 expressions increased significantly with high-risk HPV infection (p=0.014), especially HPV type 16 and 58. Ki-67 expression was not related with high-risk HPV. There was positive correlation between the expression of the p16 and Ki-67 (p=0.007). CONCLUSION: CIN grade were positively related to the expression of p16 and Ki-67. p16 expressions of high-risk HPV specimens significantly increased more than Ki-67. Therefore, in the diagnosis of CIN and high-risk HPV infection, p16 can be a useful biomarker.

Endometrial Stromal Sarcomas: A Retrospective Analysis of 28 Patients, Single Center Experience for 20 Years / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The aim of this study was to evaluate the behavior of endometrial stromal sarcomas (ESSs) in relation to their clinical and pathogenic features, and to determine the optimal treatment strategy. MATERIALS AND METHODS: A retrospective analysis was performed involving 28 patients with histologic-proven ESSs treated at our institution between 1987 and 2006. RESULTS: The median follow-up was 54.7+/-63.1 months and the 5-year survival rate was 82.0%. Twenty-two (81.5%) and 5 patients (18.5%) had low- and high-grade disease, respectively. Univariate analysis revealed that the histologic grades, based on mitotic count, were associated with longer survival (p=0.004). However, among those patients with low-grade tumors, 5/20 patients (25%) had a recurrence and 2/21 patients (9.5%) had distant metastasis during the follow-up period. With the exception of 2 patients, 26 patients with ESSs underwent hysterectomy as primary treatment. Adjuvant treatment after surgery was administered to 14/26 patients (53.8%). Hormone therapy with progesterone, chemotherapy, and/or radiotherapy did not influence overall survival. However, the postoperative adjuvant therapy group, regardless of the treatment modality, was associated with relatively increased overall survival when compared to the surgery only group (p=0.054). CONCLUSION: The preoperative differential diagnosis of ESSs from other benign gynecologic diseases is often difficult. We recommend adjuvant therapy be administered after hysterectomy in patients with ESS to prevent recurrence or distant metastasis.

Comparison of modified Cherney incision and vertical midline incision for management of early stage cervical cancer / 부인종양

OBJECTIVE: The aim of this study was to compare operative feasibility and surgical outcome of the modified Cherney incision and vertical midline incision in patients undergoing radical hysterectomy and pelvic lymphadenectomy. METHODS: Between March 2005 and December 2007, retrospective data of 78 patients (n=17; modified Cherney incision, n=61; vertical midline incision) with early stage cervical cancer who received radical hysterectomy and pelvic lymphadenectomy were reviewed. RESULTS: Baseline characteristics of patients who underwent modified Cherney incision and vertical midline incision were similar except for age (mean+/-SD: 32.3+/-3.4 yr vs. 52.5+/-8.4 yr, p<0.001). Patients who received modified Cherney incision had earlier initiation of soft diet (mean+/-SD: 46.5+/-19.5 hr vs. 56.4+/-25.4 hr, p<0.016) and shorter hospital stay compared to those who received vertical midline incision (mean+/-SD: 18.0+/-4.8 days vs. 21.7+/-3.7 days, p<0.042). There was no difference in the number of dissected pelvic lymph nodes, hemoglobin change, postoperative pain, postoperative ileus, Foley indwelling duration, and perioperative complications. CONCLUSION: Excluding the selection bias for age, there was no significant difference of the clinical outcome between the modified Cherney incision group and the vertical midline incision group. Modified Cherney incision can be cosmetically performed in young age women obtaining equal number of lymph nodes without increased operative morbidity compared to vertical midline incision.

Comparison of modified Cherney incision and vertical midline incision for management of early stage cervical cancer / 부인종양

OBJECTIVE: The aim of this study was to compare operative feasibility and surgical outcome of the modified Cherney incision and vertical midline incision in patients undergoing radical hysterectomy and pelvic lymphadenectomy. METHODS: Between March 2005 and December 2007, retrospective data of 78 patients (n=17; modified Cherney incision, n=61; vertical midline incision) with early stage cervical cancer who received radical hysterectomy and pelvic lymphadenectomy were reviewed. RESULTS: Baseline characteristics of patients who underwent modified Cherney incision and vertical midline incision were similar except for age (mean+/-SD: 32.3+/-3.4 yr vs. 52.5+/-8.4 yr, p<0.001). Patients who received modified Cherney incision had earlier initiation of soft diet (mean+/-SD: 46.5+/-19.5 hr vs. 56.4+/-25.4 hr, p<0.016) and shorter hospital stay compared to those who received vertical midline incision (mean+/-SD: 18.0+/-4.8 days vs. 21.7+/-3.7 days, p<0.042). There was no difference in the number of dissected pelvic lymph nodes, hemoglobin change, postoperative pain, postoperative ileus, Foley indwelling duration, and perioperative complications. CONCLUSION: Excluding the selection bias for age, there was no significant difference of the clinical outcome between the modified Cherney incision group and the vertical midline incision group. Modified Cherney incision can be cosmetically performed in young age women obtaining equal number of lymph nodes without increased operative morbidity compared to vertical midline incision.

Two Cases of Ectopic Pregnancy Implanted in the Previous Cesarean Section Scar Treated with Dilatation and Evacuation after Vaginal Misoprostol / 대한산부인과학회잡지

Implantation of a pregnancy within the scar of previous cesarean section is the rarest form of ectopic pregnancy. If diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. However, delayed diagnosis and treatment can lead to uterine rupture, hemorrhage and maternal morbidity. We present two cases of ectopic pregnancy developing in the previous cesarean section scar in which successfully treated with dilatation and evacuation after vaginal misoprostol.

Nuchal Translucency Measurement in Normal Korean Fetuses at 10-14 Weeks of Gestation(II) / 대한산부인과학회잡지

The aim of the present cross-sectional study is to define the reference range for the nuchal translucency (NT) measurements in normal Korean fetuses between 10 and 14 weeks' gestation. The nuchal translucency was measured prospectively in 202 chromosomally normal singletons of women attending our antenatal clinic or prenatal diagnostic center by 177 transabdominal sonography (88%) and by 25 transvaginal sonography (12%) if difficulty was encountered with transabdominal sonography. The NT measurement was expressed as the median and 5th, 95th centiles according to crown-rump length (CRL) measurements by ultrasound. Mean multiple of median (MoM) and the 95th centile of MoM values of the NT measurements with CRL in 10 mm intervals were also calculated. NT measurements increased significantly with CRL[NT (mm)=0.481647+0.020142xCRL (mm)]. A NT measurement greater than 2.5 mm was found in 4% of normal fetuses, but this proportion increased form 0% at 10-11 weeks, to 3.8, 8.8, 11.5% at 12, 13, 14 weeks, respectively. The present study provides normative data on the fetal NT thickness in a Korean population, which may improve the performance of NT screening for chromosomal abnormalities in the first trimester.

A Case of Heterotopic Pregnancy after Ovulation Induction / 대한산부인과학회잡지

Heterotopic pregnancy, simultaneous intrauterine and extrauterine pregnancy, classically was considered a exceedingly rare obstetrical phenomenon. But nowadays the natural incidence is increasing and especially in association with assisted reproductive technologies, such as use of variable methods for ovulation inductions, in-vitro fertilization and embryo transfer, and gamate intrafallopian transfer. In spite of the difficult early diagnosis, which is potentially dangerous to the mother and fetus, the maternal mortality, morbidity and fetal loss is low when the diagnosis is made in timely fashion and proper management is achieved. The presence of a intrauterine pregnancy dose not exclude the possibility of a extrauterine pregnancy, and in women associated with assisted reproductive technologies, the possibility of a heterotopic pregnancy should be considered. We report a case of a heterotopic pregnancy following ovulation induction and intrauterine insemination with brief review of literature.

A Case of Congenital Duodenal Atresia Diagnosed by Prenatal Ultrasonography / 대한주산의학회잡지

Congenital duodenal atresia is the most common cause of perinatal intestinal obstruction. Abdominal distension and projectile vomiting are the specific symptoms of neonatal gastro-intestinal obstruction. The incidence of duodenal atresia is between 1 in 2,710 and 1 in 10,000 live births.1 Most cases are thought to be failure of recanalization of the duodenal lumen during embryonic period.2 Duodenal atresia is associated with a high incidence of other associational anomalies, including esophageal atresia, biliary atresia, congenital heart disease and vertebral anomalies. Prenatal diagnosis, the ealry operation and the facotrs such as prematurity, combined abnormalities, nutirtion have a significant influence on complication and mortality.3,4 We report a case of congenital duodenal atresia diagnosed by ultrasonography prenatally in Andong general hostpital at 26 gestational weeks and operated the 7th day of cesarean section in Yeungnam university hospital with a brief review of literature.

A case of Deletion of Chromosome 4p / 대한산부인과학회잡지

We have known that deletion of chromosomal 4p resulted Wolf-Hirschhorn syndrome. Wolf-Hirschhorn syndrome, first described in 1965 by Wolf et al and Hirschhorn et al, is defined multiple congenital anomalies and mental retardation syndrome resulting from deletion involving chromosomal band 4p. The main features of this syndrome are microcephaly, frontal bossing, dolycocephaly, hypoplasia of the eye socket, ptosis, strabismus, nystagmus, bilateral epicanthic folds, cleft lip, palate, beaked nose, hypospadias, cardiac malformations and mental retardation (IQ 20-30). As we experience a case of deletion of chromosome 4p by doing cytogenetic study due to abscence of fetal stomach on sonography and increased fetal nuchal folds, we report our case with a literature review.