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.

Factors associated with parametrial involvement in patients with stage IB1 cervical cancer: Who is suitable for less radical surgery?

OBJECTIVE: To detect the possible clinicopathologic factors associated with parametrial involvement in patients with stage IB1 cervical cancer and to identify a cohort of patients who may benefit from less radical surgery. METHODS: We retrospectively reviewed 120 patients who underwent radical hysterectomy and pelvic lymphadenectomy as treatment for stage IB1 cervical cancer. RESULTS: Overall, 18 (15.0%) patients had parametrial tumor involvement. Tumor size larger than 2 cm, invasion depth greater than 1 cm, presence of lymphovascular space involvement (LVSI), corpus involvement, and positive lymph nodes were statistically associated with parametrial involvement. Multivariate analysis for other factors showed invasion depth >1 cm (P=0.029), and corpus involvement (P=0.022) were significantly associated with parametrial involvement. A subgroup with tumor size smaller than 2 cm showed no parametrial involvement, regardless of invasion depth or presence of LVSI. CONCLUSION: Tumor size smaller than 2 cm showed no parametrial involvement, regardless of invasion depth or presence of LVSI. Invasion depth >1 cm and corpus involvement were significantly associated with parametrial involvement in multivariate analysis. These finding may suggest that tumor size may a strong predictor of parametrial involvement in International Federation of Gynecology and Obstetrics stage IB1 cervical cancer, which can be used to select a subgroup population for less radical surgery.

The influence of hormone therapy with drospirenone-estradiol on endometrioid type endometrial cancer patients / 부인종양

OBJECTIVE: To determine whether drospirenone/estradiol (DRSP/E2) has an adverse effect on clinical outcomes in surgically staged International Federation of Gynecology and Obstetrics (FIGO) stage I/II endometrial cancer (EC) patients. METHODS: In a retrospective case-controlled study, 58 women with EC who had received DRSP/E2 postoperatively were compared with 116 women who had not. And, oncologic safety of postoperative hormone therapy with DRSP/E2 in EC survivors were compared between the 2 groups after propensity score matching using a logistic regression model. RESULTS: The median ages were 47.7 years and 53.6 years for the study and the control groups, respectively (p < 0.001). The study group had similar parity (p = 0.71), lower body mass index (p = 0.03) and more premenopausal women (p < 0.001) than the control group. The stages were completely matched. The grades (p = 0.42), lymphovascular space invasion (p = 0.23), preoperative cancer antigen 125 (CA 125) level (p = 0.89), and hormone receptor status (p = 0.07) were similar in both groups. The median tumor diameter was statistically larger in the study group than in the control group (p < 0.001). Both group received similar adjuvant therapy (p = 0.80). In the propensity matching, only hormone receptor status was significantly different (p = 0.03). In the univariate analysis, only stage was significantly associated with disease-free survival (DFS) and there was no variable associated with overall survival (OS). And, there was no significant factor identified in multivariate analysis. The difference in the DFS (p = 0.63) and in the OS (p = 0.32) was not significant. The same results were obtained after propensity score matching. CONCLUSION: Postoperative hormone therapy with DRSP/E2 in EC survivors did not increase recurrence or the death rate.

Effect of tibolone on the survival of early stage cervical adenocarcinoma patients

OBJECTIVE: Gynecologic oncologists are uncertain about the safety of tibolone application in cervical adenocarcinoma (AC) patients. This study examined the possible adverse effects of tibolone on the survival of cervical AC patients. METHODS: Medical records of 70 cervical AC patients with International Federation of Gynecology and Obstetrics stages IA to IB were reviewed. A bilateral salpingo-oophorectomy was performed in all patients, and survival outcomes between tibolone users (n=38) and non-users (n=32) were compared. RESULTS: A comparison of the tibolone users with non-users revealed similar clinicopathological variables. Progression-free survival (P=0.34) and overall survival (P=0.22) were similar in the users and non-users. The risks of progression (hazard ratio [HR], 1.71; 95% confidence interval [CI], 0.46–6.37; P=0.43) and death (HR, 1.59; 95% CI, 0.06–45.66; P=0.79) were also similar in both groups. CONCLUSION: Tibolone has no adverse effect on the survival of cervical AC patients and can be administered safely to this population. These findings may be helpful in improving the quality of life of cervical AC patients.

Comparison between adjuvant chemotherapy and adjuvant radiotherapy/chemoradiotherapy after radical surgery in patients with cervical cancer: a meta-analysis / 부인종양

OBJECTIVE: To estimate the effect of adjuvant chemotherapy (AC) on the prognosis in cervical cancer patients with intermediate- or high-risk factors after radical hysterectomy (RH) compared to that for adjuvant radiotherapy (AR). METHODS: The Embase and MEDLINE databases and the Cochrane Library were searched for published studies comparing cervical cancer patients who received AC with those who received AR after RH. The endpoints were patient oncologic outcome. Random-effects meta-analytical models were used to calculate the pooled estimates of the effect of AC on mortality/recurrence. RESULTS: Two randomized trials and eleven observational studies (AC, 942 patients; AR, 1,721 patients) met our search criteria. There were no significant differences in mortality and any recurrence between two groups. The results for distant recurrence favored the AC group (pooled odds ratio: 0.69; 95% confidence interval: 0.54–0.88; p=0.03). In subgroup analyses (for study design, histology, indication for adjuvant treatment, AR type, AC type, and lymph node metastasis), there was no significant increase in mortality and recurrence for AC compared with that for AR. CONCLUSION: Compared to AR, AC showed similar survival outcomes in cervical cancer patients undergoing RH and also appeared to reduce the risk of distant recurrence.

Use of a cognitive computing system for treatment of cervical cancer / 부인종양

No abstract available.

Surgical manual of the Korean Gynecologic Oncology Group: classification of hysterectomy and lymphadenectomy / 부인종양

The Surgery Treatment Modality Committee of the Korean Gynecologic Oncologic Group (KGOG) has determined to develop a surgical manual to facilitate clinical trials and to improve communication between investigators by standardizing and precisely describing operating procedures. The literature on anatomic terminology, identification of surgical components, and surgical techniques were reviewed and discussed in depth to develop a surgical manual for gynecologic oncology. The surgical procedures provided here represent the minimum requirements for participating in a clinical trial. These procedures should be described in the operation record form, and the pathologic findings obtained from the procedures should be recorded in the pathologic report form. Here, we focused on radical hysterectomy and lymphadenectomy, and we developed a KGOG classification for those conditions.

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

Clinical practice guidelines for gynecologic cancers have been developed by academic society from several countries. Each guideline reflected their own insurance system and unique medical environment, based on the published evidence. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to develop the third edition of the guidelines in an advanced format based on evidence-based medicine, embracing up-to-date clinical trials and qualified Korean data. These guidelines cover strategies for diagnosis and treatment of primary and recurrent cervical cancer. The committee members and many gynecologic oncologists derived key questions through discussions, and a number of relevant scientific literature were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the management in cervical cancer based on the results in published papers to date and the consensus of experts as a KSGO Consensus Statement.

The influence of number of high risk factors on clinical outcomes in patients with early-stage cervical cancer after radical hysterectomy and adjuvant chemoradiation

OBJECTIVE: The purpose of this study was to evaluate the prognosis according to the number of high risk factors in patients with high risk factors after radical hysterectomy and adjuvant chemoradiation therapy for early stage cervical cancer. METHODS: Clinicopathological variables and clinical outcomes of patients with FIGO (International Federation of Gynecology and Obstetrics) stage IB1 to IIA cervical cancer who had one or more high risk factors after radical hysterectomy and adjuvant chemoradiation therapy were retrospectively analyzed. Patients were divided into two groups according to the number of high risk factors (group 1, single high risk factor; group 2, two or more high risk factors). RESULTS: A total of 93 patients were enrolled in the present study. Forty nine out of 93 (52.7%) patients had a single high risk factor, and 44 (47.3%) had two or more high risk factors. Statistically significant differences in stage and stromal invasion were observed between group 1 and group 2. However, age, histology, tumor size, and lymphovascular space invasion did not differ significantly between the groups. Distant recurrence occurred more frequently in group 2, and the probability of recurrence and death was higher in group 2. CONCLUSION: Patients with two or more high risk factors had worse prognosis in early stage cervical cancer. For these patients, consideration of new strategies to improve survival may be worthwhile. Conduct of further clinical trials is warranted for development of adjuvant treatment strategies individualized to each risk group.

A Case of Ovarian Steroid Cell Tumor, Not Otherwise Specified, Treated with Surgery and Gonadotropin Releasing Hormone Agonist

Steroid cell tumors account for less than 0.1% of all ovarian tumors. There are three steroid cell tumor subtypes: steroid cell tumor not otherwise specified (NOS), stromal luteoma and Leydig cell tumor. Steroid cell tumor, NOS, is the most common type and has malignant potential. This report describes a case of an ovarian steroid cell tumor, NOS. A 35-year-old woman visited hospital with the complaint of metrorrhagia. Physical examination revealed increased pubic hair. Transvaginal ultrasound indentified a 4.9 x 3.4 cm, well-circumscribed and solid left ovarian tumor. After laparoscopic left oophorectomy, the tumor was revealed as an ovarian steroid cell tumor, NOS. During the laparoscopic surgery, tumor ruptured. Complete surgical staging was performed and no evidence of metastasis was found. Gonadotropin releasing hormone agonist was administered monthly for 6 months. The patient has had no evidence of recurrence for 43 months.

Papillary Cystadenoma of the Fallopian Tube Not Associated with von Hippel-Lindau Disease: A Case Report

No abstract available.

An association between preoperative anemia and poor prognostic factors and decreased survival in early stage cervical cancer patients

OBJECTIVE: To evaluate correlation of preoperative anemia with clinical outcomes in patients with early stage cervical cancer who were treated with radical hysterectomy and lymph node dissection. METHODS: Patients who underwent radical hysterectomy and lymph node dissection for cervical cancer from January 2001 to February 2012 were included in this study. Clinicopatholgoical factors included in univariate and multivariate analysis were age, tumor histology, FIGO (International Federation of Gyneocology and Obstetrics) stage, preoperative hemoglobin, depth of invasion, tumor size, parametrial involvement, resection margin, and lymph node status. RESULTS: A total of 387 patients were retrospectively analyzed in this study; 141 patients (36.4%) had preoperative anemia (hemoglobin <12 g/dL) and 16 out of 141 patients (11.3%) received blood transfusion for correction of preoperative anemia. Patients with preoperative anemia showed significant association with age <50 years, more advanced stage, non-squamous cell carcinoma histology, larger tumor size, deeper stromal invasion, and lymph node metastasis (P<0.05). Both relapse-free survival and overall survival were worse in patients with preoperative anemia in univariate analysis. In multivariate analysis, overall survival was worse in patients with preoperative anemia, but relapse-free survival was not associated with preoperative anemia. In the intergroup analysis of anemic patients for the effect of preoperative blood transfusion, preoperative anemia correction did not affect survival. CONCLUSION: Preoperative anemia was not an independent prognostic factor for survival in patients with early cervical cancer. However, it was associated with poor prognostic factors. Further study in large population is needed.

The feasibility and efficacy of gonadotropin-releasing hormone agonists for prevention of chemotherapy induced ovarian failure in patient with gynecological malignancies

OBJECTIVE: To assess the effects of a gonadotropin-releasing hormone agonist (GnRH-a) depot (Leuprolide acetate) in women with gynecologic cancer receiving chemotherapy while taking a continuous add-back on the prevention of premature ovarian failure. METHODS: Fourteen premenopausal patients with gynecological malignancies who had undergone conservation of ovaries surgery received a GnRH-a depot plus add-back until chemotherapy was completed. Four weeks thereafter, a hormonal profile (follicle stimulating hormone) was measured. RESULTS: The mean follicle stimulating hormone level was 15.8 IU/L. All patients exhibited a restoration of ovarian failure during follow-up. One patient became pregnant during the follow-up period. CONCLUSION: In the short term, GnRH-a appears to protect ovarian function and ability to achieve pregnancy following chemotherapy. The result of our study needs further elucidation in a large randomized controlled trial.

A case of successful salvage chemotherapy of recurrent ovarian sertoli-leydig cell tumor

Sertoli-Leydig tumors tend to relapse early and due to their rarity, limited data are available regarding a role of chemotherapy in the management of Sertoli-Leydig cell tumors. We present a case of recurrent ovarian Sertoli-Leydig cell tumor whose salvage treatment was successful with paclitaxel and carboplatin chemotherapy.

Retained placenta accreta after a first-trimester abortion manifesting as an uterine mass

Placenta accreta during the first trimester of pregnancy is rare. Only a few cases of placenta accreta manifesting as a uterine mass have been published. Most patients with placenta accreta present with vaginal bleeding during or after pregnancy. This report describes a patient with placenta accreta that caused vaginal bleeding three years after a first trimester abortion. The patient had regular menstruation for three years after the abortion. Initially endometrial cancer or a uterine myoma with degeneration was suspected. This is the first report of a placenta accreta detected as a uterine mass long after a first trimester abortion with delayed vaginal bleeding.

Laparoscopic management of endometrial cancer according to body mass index; a Korean Outcome Research & Analysis in Gynecologic Cancers (KORAGCs) Study / 대한산부인과내시경학회지

OBJECTIVE: To compare clinicopathologic characteristics and surgical outcomes of laparoscopic surgery in women with endometrial cancer according to body mass index (BMI). METHODS: From June 2009 to October 2010, prospective observational study without randomization of 159 patients treated by laparoscopic surgery from 10 hospitals nationwide. RESULTS: Patients were divided according to the WHO guidelines for Asia-Pacific populations and the distributions of BMI were as follows: 3 patients (1.9%) in underweight (BMI or = 30.0 kg/m2). Age, history of previous surgery, surgery extend, and history of previous surgery were not different between non-obese patients (BMI or = 25.0 kg/m2). Co-morbidities were more common in obese patients but marginally significant (23.5% vs. 37.7%, p=0.072). Four patients (2.5%) were converted to abdominal surgery because of severe adhesion. Regarding to surgical outcomes, operation time was significantly longer in obese patients (199 min vs. 235 min, p=0.013) but blood loss, lymph node yield, hospital stay, Foley removal, transfusion rate and peri-operative complication were not statistically significant. Regarding to pathologic results, there were no difference in terms of lymphovasucular space invasion, tumor grade, histologic type, lymph node metastasis and FIGO stage. CONCLUSION: Clinicopathologic characteristics and surgical outcomes does not seem to be significantly influenced by BMI except operation time. So the laparoscopic approach can be the alternative method for obese patients.

Radiation therapy with chemotherapy for patients with cervical cancer and supraclavicular lymph node involvement / 부인종양

OBJECTIVE: We wanted to evaluate the outcomes of cervical cancer patients with supraclavicular lymph node (SCLN) involvement and who received radiation therapy (RT) combined with chemotherapy. METHODS: From August 2001 to April 2009, nine cervical cancer patients with SCLN involvement were treated by RT and cisplatin-based chemotherapy. Most of the patients (8/9, 88.9%) also had a positive para-aortic lymph node (PALN). The RT field was designed to include the whole pelvis, the involved PALNs and the SCLN area. The median SCLN RT dose was 66.6 Gy (range, 60 to 70 Gy). RESULTS: The median follow-up period was 61 months (range, 13 to 98 months). The 3- and 5-year overall survival rates were 66.7% and 55.6%, respectively and the 3- and 5-year progression-free survival rates were 66.7% and 44.4%, respectively. The acute hematologic toxicities according to the criteria of Radiation Therapy of Oncology Group (RTOG) were G1/2 leucopenia in 3 (33.3%), G3/4 leukopenia in 6 (66.7%), G1/2 anemia in 7 (77.8%), G3 anemia in 1 (11.1%), G2 thrombocytopenia in 2 (22.2%), and G3/4 thrombocytopenia in 2 (22.2%). Within 6 months after RT, most of the patients (5/6, 83.3%) recovered from the G3/4 leukopenia, except for 1 patient who received chemotherapy after completing RT due to subsequent bone metastasis. CONCLUSION: For patients with advanced cervix cancer and SCLN involvement, RT with chemotherapy as active therapy can be expected to provide favorable results, although there is an increased risk of G3/4 hematologic toxicity.

Recurrent ovarian cancer metastatic to the bone: Case report / 대한산부인과학회지

In patients with gynecologic malignancies, bone metastases are unusual and generally occur in a more advanced stage of the disease with extended local invasion of the primary site and/or parenchymal metastasis. In ovarian cancer, the main route of spread is intraperitoneal implantation and loco-regional invasion, whereas extraperitoneal spread usually implies advanced disease. Bone metastasis from ovarian cancer is rare and occurs in approximately 1% of primary or recurrent disease. The prognosis of cases with bone metastasis is poor. We report a patient with metastases to the sternum and a rib after prolonged treatment and a patient with recurrent ovarian cancer metastatic to the sacrum 8 months after primary treatment.

Oculocardiac Reflex during Endoscopic Sinus Surgery: A case report / 대한마취과학회지

The oculocardiac reflex is provoked by pressure applied to the globe of the eye or traction on the surrounding structures. It has been known that children and adults undergo eye muscle surgery under general anesthesia are most susceptible. When it occurs the most common manifestation is sinus bradycardia and other arrhythmia including atrioventricular block, ventricular premature beat and cardiac arrest. Endoscopic sinus surgery has been used popularly for treatment of chronic paranasal sinusitis. However endoscopic sinus surgery can be difficult for narrow visual field and anatomical variations. Oculocardiac reflex during endoscopic sinus surgery is rare case but potentially it can be life threatening event. The authors report the case of oculocardiac reflex during endoscopic sinus surgery with a review of literature.

Concurrent chemoradiation therapy in cervical cancer with para-aortic lymph node involvement / 부인종양

OBJECTIVE: This study was undertaken to evaluate the therapeutic results and complications after concurrent chemoradiation therapy and to investigate the prognostic factors for cervical cancer with para-aortic lymph node involvement. METHODS: From May 1999 to August 2005, thirty eight patients with cervical cancer, treated by combined platinum base chemotherapy and extended field radiation therapy in Gachon University Gil medical center. All patients were diagnosed as paraaortic lymphnode involvement with imaging studies. The radiation dose of external beam was 34.2-64.4 Gy to whole pelvis and 32.4-59.4 Gy to paraaortic area. Cisplatin based chemotherapy was done simultaneously. We evaluated the prognostic factors such as stage, tumor size, inguinal and supraclavicular lymphnode status, and radiation doses. RESULTS: Median follow-up period is 34 months (7-85 months). The 3 year overall and disease free survival rates were 63.6% and 56.4%, respectively. There was no case of recurrence after 3 years of treatment. In 2 patients, the treatment was not completed because of Grade III or IV gastroenteral complications; abdominal pain and diarrhea. Grade III or IV hematologic complications were occurred in fifteen patients, but all patients were recovered without serious complications. We could not find any significant prognostic factors in this study. CONCLUSION: Concurrent chemoradiation therapy for cervical cancer with paraaortic lymph node involvement is well tolerable and effective treatment.