Practice guidelines for management of ovarian cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement / 부인종양

Since after 2006 when the first edition of practice guidelines for gynecologic oncologic cancer treatment was released, the Korean Society of Gynecologic Oncology (KSGO) has published the following editions on a regular basis to suggest the best possible standard care considering updated scientific evidence as well as medical environment including insurance coverage. The Guidelines Revision Committee was summoned to revise the second edition of KSGO practice guidelines, which was published in July 2010, and develop the third edition. The current guidelines cover strategies for diagnosis and treatment of primary and recurrent ovarian cancer. In this edition, we introduced an advanced format based on evidence-based medicine, collecting up-to-date data mainly from MEDLINE, EMBASE, and Cochrane Library CENTRAL, and conducting a meta-analysis with systematic review. Eight key questions were raised by the committee members. For every key question, recommendations were developed by the consensus meetings and provided with evidence level and strength of the recommendation.

Single-port laparoscopic debulking surgery of variant benign metastatic leiomyomatosis with simultaneous lymphatic spreading and intraperitoneal seeding

Benign metastatic leiomyomatosis (BML) is a rare disease characterized by smooth muscle cell proliferation in extrauterine sites including the lung, abdomen, pelvis, and retroperitoneum. Depending on location, BML is classified as intravenous leiomyomatosis and diffuse peritoneal leiomyomatosis. Pathogenesis of BML can be iatrogenic after previous myomectomy or hysterectomy, hormonal, or coelomic metaplasia. Treatment options are observation, hormonal suppression, and/or surgical debulking via laparotomy or laparoscopy. Laparoscopic surgery is gaining in popularity in the gynecologic field compared to laparotomic surgery and single-port laparoscopy has the benefits of cosmesis and early tissue extraction by transumbilical morcellation. We report a 39-year-old woman with BML who underwent single-port laparoscopy debulking surgery.

Postoperative Radiotherapy Alone Versus Chemoradiotherapy in Stage I-II Endometrial Carcinoma: An Investigational and Propensity Score Matching Analysis / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to compare the results of postoperative adjuvant radiotherapy (RT) and concurrent chemoradiotherapy (CRT) in stage I-II endometrial carcinoma. MATERIALS AND METHODS: We analyzed a total of 64 patients with surgically staged I-II endometrial carcinoma who were treated with postoperative adjuvant RT or concurrent CRT between March 1999 and July 2013. Thirty-two patients who received postoperative RT alone were matched with those who received postoperative CRT (n=32) in accordance to age, stage, and tumor histology. Overall survival and relapse-free survival, as well as toxicity of the RT and CRT arms were evaluated and compared. RESULTS: The 5-year overall survival rate was 90.0% for the RT arm and 91.6% for the CRT arm. There was no significant difference in overall survival between the two treatment arms (p=0.798). The 5-year relapse-free survival rate was 87.2% in the RT arm and 88.0% in the CRT arm. Again, no significant difference in relapse-free survival was seen between the two arms (p=0.913). In a multivariate analysis, tumor histology was an independent prognostic factor for relapse-free survival (hazard ratio, 3.67; 95% of CI, 2.34 to 7.65; p=0.045). Acute grade 3 or 4 hematologic toxicities in the CRT arm were significantly higher than in the RT alone arm (6.2% vs. 31.2%, p=0.010). CONCLUSION: Adjuvant pelvic concurrent chemoradioherapy did not show superior results in overall survival and relapse-free survival compared to RT alone in stage I-II endometrial carcinoma.

Use of a Silicone Gel Sheet Vaginal Mold in McIndoe Vaginoplasty

No abstract available.

Treatment outcome in patients with vulvar cancer: comparison of concurrent radiotherapy to postoperative radiotherapy

PURPOSE: To evaluate outcome and morbidity in patients with vulvar cancer treated with radiotherapy, concurrent chemoradiotherapy or postoperative radiotherapy. MATERIALS AND METHODS: The records of 24 patients treated with radiotherapy for vulvar cancer between July 1993 and September 2009 were retrospectively reviewed. All patients received once daily 1.8-4 Gy fractions external beam radiotherapy to median 51.2 Gy (range, 19.8 to 81.6 Gy) on pelvis and inguinal nodes. Seven patients were treated with primary concurrent chemoradiotherapy, one patient was treated with primary radiotherapy alone, four patients received palliative radiotherapy, and twelve patients were treated with postoperative radiotherapy. RESULTS: Twenty patients were eligible for response evaluation. Response rate was 55% (11/20). The 5-year disease free survival was 42.2% and 5-year overall survival was 46.2%, respectively. Fifty percent (12/24) experienced with acute skin complications of grade III or more during radiotherapy. Late complications were found in 8 patients. 50% (6/12) of patients treated with lymph node dissection experienced severe late complications. One patient died of sepsis from lymphedema. However, only 16.6% (2/12) of patients treated with primary radiotherapy developed late complications. CONCLUSION: Outcome of patients with vulvar cancer treated with radiotherapy showed relatively good local control and low recurrence. Severe late toxicities remained higher in patients treated with both node dissection and radiotherapy.

Lipomatous variant of angiomyofibroblastoma on the vulva: A case report / 대한산부인과학회지

Lipomatous variant of angiomyofibroblastoma is a rare tumor of the vulva. Most of cases are usually premenopausal and present with a slowly growing mass without pain. A 46-year-old woman presented with a swelling of the left labium major. The lesion was thought to be a Batholin's gland cyst or a lipoma preoperatively and a local excision was performed. The tumor was well demarcated and rubbery. On microscopic examination, the alternating hypercellular and edematous hypocellular component with abundant vessels was noted. A large amount of adipose tissue was scattered in the lesion. Stromal cells were positive for vimentin, estrogen receptor, and progesterone receptor and negative for desmin antibody immunostaining. The local excision was enough for complete treatment. No recurrence was noted for 7 months after surgery.

Effects of laparoscopic surgery on the immune system of the patients with gynecologic diseases / 대한산부인과학회지

OBJECTIVE: Elective surgical approaches and trauma cause changes in the production of different cytokines. The aim of this study was to evaluate the effects of laparoscopic surgery on the immune system of patients with gynecologic diseases. METHODS: We recruited the open surgery group (n=20) and laparoscopic surgery group (n=33). In a prospective study we examined the C-reactive protein (CRP) level, the production of the cytokines Interleukin-1beta (IL-1beta), Interleukin-6 (IL-6), Interleukin-8 (IL-8), Interleukin-10 (IL-10) and TNF-alpha concentrations by ELISA. In addition the fibrinogen, transferrin, albumin, hemoglobin and hematocrit were measured. Statistical analysis was made by Mann-Whitney U test and Kruskal-Wallis test. RESULTS: There were significant statistical differences in the CRP, IL-6 and IL-8 between the open surgery group and laparoscopic surgery group after surgery. The CRP and IL-8 showed a more distinct increase in open surgery group 24 hours after surgery, the differences between the two surgical approaches were significant (p<0.05). CONCLUSION: Elective surgical approaches cause changes in the immune system, which can be evaluated by the reaction of cytokines. Laparoscopic surgery cause less activation of the CRP and IL-8 than open surgery.

A case of sarcoma arising in ovarian mature cystic teratoma / 대한산부인과학회지

Benign cystic teratoma is the common ovarian tumor, and the incidence reported about 20%. Between 1 and 2% of mature cystic teratomas undergo malignant trasformation. This occurs most frequently in postmenopausal women, who account for only 10% of mature cystic teratomas. Among the malignant transformations, squamous cell carcinoma is the most common type (over 75%), and adenocarcinoma, undifferentiated carcinoma, malignant melanoma, thyroid adenocarcinoma, and sarcoma have been reported in the literature. Because of its rarity, the clinico-pathologic characteristics are not well established, and there is no consensus on optimal therapy. There is also no consensus regarding the efficacy of postoperative therapy. We experienced a case of sarcoma of the ovary arising in mature cystic teratoma, which is presented with a brief review of literature.

A case of transverse vaginal septum with modified Garcia technique / 대한산부인과학회지

The incidence of all transverse vaginal septum is 1:2,100 - 1:72,000. The transverse vaginal septum is a developmental defect of vagina which may be fused incompletely between the Mullerian duct component and the urogenital sinus component of vagina. Serious complications may be hematocolpos, hematometra and hematosalpinx. Simple surgical excision or simple incision have been developed to treat congenital transverse vaginal septa, but also caused common complications such as secondary tissue contracture. Garcia technique using eight vaginal mucosa flaps was developed to avoid common complication of secondary vaginal stenosis. Here, we present a case of contracted transverse vaginal septum who has been performed a simple incision 13 years ago, successfully performed the modified Garcia technique without serious postoperative complication.

Clinical value of serum vascular endothelial growth factor (VEGF) in ovarian diseases / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate the concentration of serum VEGF and its relationship with the clinical parameters and the tumor markers in ovarian diseases. METHODS: We measured the serum VEGF concentrations by ELISA in 76 patients with benign ovarian disease, as well as 9 normal volunteers, 4 patients with ovarian borderline malignancy and 53 patients with ovarian cancer. RESULTS: There is a significant statistical difference between the serum VEGF levels in patients with benign ovarian disease (157.7+/-197.8 pg/ml) and ovarian cancer (344.7+/-372.2 pg/ml) (p<0.005). CONCLUSION: Serum VEGF may help in the differential diagnosis between benign and malignant ovarian disease. We suggest that serum VEGF may be useful as a diagnostic tool in ovarian disease.

A case of uterine inversion resulted from prolapse of huge pedunculated uterine submucosal leiomyoma / 대한산부인과학회지

Uterine leiomyomas are the most common uterine tumors. They are estimated to be present in approximately 20% of all women of reproductive age. They may be present in subserosal, intramural, or submucosal in location within the uterus, or located in the cervix, in the broad ligaments, or on a pedicle. Many studies report that the malignant potential of a preexisting uterine leiomyoma is extremely rare, occuring in less than 0.5%. Uterine leiomyomas may cause a range of syptoms, for example, severe anemia from abnormal uterine bleeding, dysmenorrhea, constipation from rectosigmoid compression, dysuria, frequency, residual sensation due to bladder compression. Patients with those symptoms or "cancer phobia" should be treated. Rare but severe symptoms associated with uterine leiomyomas are rectosigmoid compression, with intestinal obstruction, thrombophlebitis of lower extremities from venous stasis, polycythemia, ascites, severe pain from torsion and infection of prolapsed pedunculated submucosal myoma and uterine inversion from prolase of pedunculated submucosal leiomyoma. Now we report a rare case of uterine inversion resulted from prolapse of huge pedunculated uterine submucosal leiomyoma, which caused hypovolemic shock due to massive uterine bleeding.

A case of successful laparoscopic surgical staging in patient of Sertoli-Leydig cell tumor / 대한산부인과학회지

Sertoli-Leydig cell tumors are rare sex cord-stromal tumors. These tumors account for less than 0.5% of all ovarian tumors. Because these tumors appear predominantly in young women (between the age of 30 and 40) and are bilateral in less than 1% of cases, conservative removal of the tumor and adjacent fallopian tube is justifiable. Recently, we experienced a case of successful laparoscopic surgical staging in patient of Sertoli-Leydig cell tumor which was previously incompletely evaluated in local OBGY clinic. There are no solid data to suggest that usefulness and risk of laparoscopic surgical staging and adjuvant therapy with stage I disease of these tumors until now. So we present it with a brief review of literature.

A case of ovarian pregnancy with focal adenomyosis mimicking cornual pregnancy that managed by laparoscopy / 대한산부인과학회지

Ovarian pregnancy is rare form of ectopic pregnancy occurring in 0.5-1% of all ectopic pregnancies. But the presenting symptom is very similar and difficult to distinguish with other forms of ectopic pregnancy. We report a case of ovarian pregnancy mimicking cornual pregnancy managed with laparoscopy. Early detection is important role in preserving fertility to avoid the ablation of functional ovarian tissue. The diagnostic criteria, etiology, and management are discussed.

A case of primary tubal cancer evaluated with laparoscopy / 대한산부인과학회지

Malignant neoplasm of the fallopian tube is the rarest of the gynecologic cancers. Vaginal bleeding, vaginal discharge, and pelvic pain are the most common symptoms. Because of these non-specific symptoms, the diagnosis of this least common neoplasm is rarely made before laparotomy. The tumor is typically unilateral and has histologic subtypes, endometrioid and serous adenocarcinoma being the most common subtypes. Surgery, clearly the mainstay of treatment, is also the first approach to diagnosis. The procedure of choice is total abdominal hysterectomy with bilateral salpingo-oopho-rectomy. We had experienced one patient with primary tubal cancer, successfully evaluated with laparoscopy. And then we intend to report the case of the above patient and have a brief discussion about that.

A case of spontaneous rupture of liver melanoma diagnosed during pregnancy / 대한산부인과학회지

The incidence of all malignant tumor in pregnancy is 0.07-0.1%. The most frequent tumors in pregnancy are breast cancer, gynecologic tumors (cervical cancer, ovarian cancer), melanoma and lymphomas. Any malignant tumor in pregnancy has a diagnostic and therapeutic problem. Melanoma is 8% of all malignancies in pregnancy. Surgery is a definitive therapy for early-stage disease. Melanoma in pregnancy metastasize early and rapidly. So we have difficulty in making therapeutic plan. Most frequent metastatic lesions are liver and lung. We experienced melanoma of liver in pregnancy. This report represents melanoma in pregnancy with a review of literature.

Early Endometrial Cancer with Multiple Bone Metastasis / 대한산부인과학회지

A 61-year old female was found to have an endometrial cancer with surgical stage Ib, grade 2. Treatment involves surgical resection followed by radiation therapy. In the middle of adjuvant radiation therapy she complained of undifined headache and tongue deviation those came from multiple skull and skeletal metastasis. Although she received the adjuvant chemo-radiation therapy but failed. Therefore we reported a case of early endometrial cancer that unusually showed multiple bone metastasis with discussion about the pretreatment evaluation for bone metastasis.

Comparisons of Propofol, Enflurane, Sevoflurane, and Desflurane Anesthesia in Laparoscopic Cholecystectomy on Postoperative Liver Enzyme Levels / 대한마취과학회지

BACKGROUND: Many factors cause postoperative hepatic dysfunction, and anesthetic agents and type of surgery are belived to contribute to hepatic dysfunction. The authors planned this study to evaluate the effect of different anesthetic agents (sevoflurane, desflurane, enflurane or propofol) on liver enzymes in the patients who undergone laparoscopic cholecystectomy. METHODS: 80 patients were randomly selected from among those who had undergone cholecystectomy and divided into 4 groups; an enflurane group (n = 20), a sevoflurane group (n = 20), a desflurane group (n = 20) and a propofol group (n = 20). Preoperative values of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were compared with those on postoperative days 1 and 3 in all groups. RESULTS: In all groups, ALT and AST were significantly elevated after operation, and then showed a decrease 3 days after operation, but remainrd of above preoperative levels (P < 0.05). However, no differences were observed between the 4 groups (P < 0.05). CONCLUSIONS: We consider that propofol, sevoflurane, desflurane and enflurane are equally usable and that they have little effect on liver function after laparoscopic cholecystectomy.

Comparison of Postoperative Pain by Different Methods in the Removal of Gases after Laparoscopic Hysterectomy / 대한마취과학회지

BACKGROUND: Laparoscopic surgery has many advantages compared with conventional methods and may allow a significant reduction in postoperative pain and analgesic consumption. Nevertheless, some patients still experience significant pain. Therefore, many clinicians have tried various methods to reduce of postoperative pain. We investigated degrees of postoperative pain and the incidences of shoulder pain versus the different methods of gas removal after laparoscopic surgery. METHODS: Sixty ASA class I or II patients were included in this study. In Group A (Control group, n = 20), residual carbon dioxide was removed by the classic method without a drain tube. In Group B (Suction group, n = 20), residual carbon dioxide was removed using a suction device aggressively without a drain tube. In Group C (Drain group, n = 20), residual carbon dioxide was removed by the classic method with a drain tube. The intensities of abdominal and shoulder pain were assessed 1, 6, 24 and 48 hours after surgery using a visual analog scale (VAS) and a verbal rating scale (VRS). We also assessed the mean hospital stay for the three groups. RESULTS: The abdominal pain scores (VAS and VRS) at 1 hour after surgery and the incidence of shoulder pain, epigastria pain and flank pain were significantly higher in Group A than in the other groups for 1hour after surgery (P <0.05). Mean hospital stay was significantly longer for group C. CONCLUSIONS: After laparoscopic surgery, the active removal of residual carbon dioxide may be a simple and safe method that significantly reduces postoperative shoulder and abdominal pain.

Induction of Anti-tumor Immunity by Vaccination with E7 of HPV16 and IL-12 / 대한산부인과학회잡지

OBJECTIVE: Interleukin-12 is well known to induce cellular immune response materials and suppress the tumor growth. HPV infection has significant roles in cervical carcinogenesis, and HPV oncoprotein E6 and E7 are important roles in formation and maintenance of cervical cancer. E7 specific immune response was detected in cervical cancer patients, and this shows that E7 protein would be important in potential immunetherapy in cervical cancer. This study is aimed to investigate antitumor effect and E7 immune response by injection of adenovirus IL-12 and E7 in cervical cancer animal model. METHODS: In the cervical cancer animal model using C57BL/6 mice and HPV16 E7 immortalized hosts, 5 X 10(8) pfu/100 ul of PBS, AdLacZ, AdE7 and AdIL-12 were injected into the tumor mass when the tumor sized is increased to 7-8 mm. After the injection, the tumor size was caliperated every 2-3 days, and pathologic and blood studies were done on day 1, 3, 5, 7, 11, 12, and 21 days. The expression level of IL-12 and INF- and E7 specific immune response were measured by ELISA. RESULTS: After the injection of AdIL-12 into the tumor mass, 45% of tumor growth suppression was noted in comparison with control group. In the cases of combination injections of AdIL-12 and AdE7, 80% growth suppression was observed, and complete regression was shown in 40% of the study group. After injection of AdIL-12, the expression of IL-12 in the tumor mass was 9 time higher than that of control group, and 6 times higher in blood sample in comparison with control group. In the group with combined AdIL-12 and AdE7, the highest expression of INF- was noted in comparison with single injection of AdIL-12 or control group. IgGI and IgG2b isotype expression level increased 2.5 times and 2.2 times respectively 3 weeks after adenovirus injection. CONCLUSION: In cervical cancer animal model, IL-12 and E7 application using Adenovirus vector is significant antitumor effect and this demonstrates the potential immunotherapy in near future.

A Case of Primary Malignant Melanoma of the Vagina / 대한산부인과학회잡지

Primary melanoma of the vagina is rare, accounting for 2.6-2.8% of all primary malignant tumor of the vagina and 0.4-0.8% of all malignant melanomas in the female. Melanocytes are the presumed precursors of malignant melanoma of the vagina; they are embryologically derived from neural crest cells and can be found in the basal portion of the vaginal epidermis in 3% of normal adult females. Though malignant melanoma may occur anywhere in the vagina, it is most commonly found on the anterior wall and in the distal one-third. Vaginal bleeding is the most common symptom. Histochemical and immunohistochemical procedures confirm the initial diagnosis. Vaginal melanoma is a highly malignant disease; due to the extensive lymphatic invasion and melanoma's propensity for hematogeneous spread, so early metastases are very common. The treatment modalities for the primary management of vaginal melanoma are varied according to the location and extend, individually or in combination, wide local incision, radical surgical extirpation, irradiation, or chemotherapy. Although there have been no consensus as to comprehensive treatment, in the case of upper vaginal melanoma, radical abdominal hysterectomy with bilateral salpingo-oophorectomy with pelvic lymph node dissection is generally advocated. Regardless of primary therapy chosen, result of the treatment of vaginal melanoma has been uniformly poor. We experienced a case of malignant melanoma of the vagina confirmed pathohistologically after radical abdominal hysterectomy with bilateral salpingo-oophorectomy and presented with a brief review of literature.