Robotic-assisted laparoscopic myomectomy: the feasibility in single-site system

OBJECTIVE: To evaluate the feasibility of robotic single-site myomectomy (RSSM). METHODS: Medical records of 355 consecutive women who underwent robotic-assisted laparoscopic myomectomy were retrospectively reviewed. Clinical characteristics were compared between multi-site and single-site systems. After 1:1 propensity score matching for the total myoma number, largest myoma size, and total tumor weight (105 women in each group), surgical outcomes were also compared between the 2 systems. RESULTS: A total of 105 (29.6%) and 250 (70.4%) women underwent RSSM and robotic multi-site myomectomy (RMSM), respectively. RSSM was more commonly performed in women with lower body mass index (21.6 vs. 22.5 kg/m2, P=0.014), without peritoneal adhesions (7.6% vs. 24.8%, P < 0.001), and less (2.6 vs. 4.6, P < 0.001) and smaller (6.3 vs. 7.7 cm, P < 0.001) myomas compared to RMSM. After propensity score matching, the largest myoma size (P=0.143), total myoma number (P=0.671), and tumor weight (P=0.510) were not significantly different between the 2 groups. Although the docking time was significantly longer in the RSSM group (5.1 vs. 3.8 minutes, P=0.005), total operation time was similar between RSSM and RMSM groups (145.9 vs. 147.3 minutes, P=0.856). Additionally, hemoglobin decrement was lower in the RSSM group than in the RMSM group (1.4 vs. 1.8 g/dL, P=0.009). No surgical complication was observed after RSSM, while 1 ileus and 2 febrile complications occurred in women that underwent RMSM (0% vs. 2.9%, P=0.246). CONCLUSION: Although RMSM is preferred for women with multiple large myomas in real clinical practice, RSSM seems to be a feasible surgical method for less complicated cases, and is associated with minimal surgical morbidity.

Uterine fibroid shrinkage after short-term use of selective progesterone receptor modulator or gonadotropin-releasing hormone agonist

OBJECTIVE: The aim of this study was to evaluate the effect of short-term use of selective progesterone receptor modulator (SPRM) or gonadotropin-releasing hormone (GnRH) agonist on uterine fibroid shrinkage among Korean women. METHODS: This retrospective study involved 101 women with symptomatic uterine fibroids who received ulipristal acetate (SPRM, n=51) and leuprolide acetate (GnRH agonist, n=50) for 3 months between November 2013 and February 2015. The fibroid volume was measured both before and after treatment using ultrasonography, computed tomography, and magnetic resonance imaging. The outcomes were compared between the SPRM and GnRH agonist groups. RESULTS: The median rate of fibroid volume reduction after SPRM treatment was 12.4% (IQR −14.5% to 40.5%) which was significantly lower than the reduction rate observed after GnRH agonist treatment (median 34.9%, IQR 14.7% to 48.6%, P=0.004). 19 of 51 (37.3%) patients with SPRM treatment did not show any response of volume shrinkage, while 7 of 50 (14.0%) women with GnRH agonist showed no response (P=0.007). CONCLUSION: Short-term SPRM treatment yields lower volume reduction than GnRH agonist treatment in Korean women with symptomatic fibroids. Further large-scale randomized trials are needed to confirm our findings.

Therapeutic outcomes of methotrexate injection in unruptured interstitial pregnancy

OBJECTIVE: To examine the therapeutic outcomes of methotrexate (MTX) in the treatment of unruptured interstitial pregnancy. METHODS: We reviewed the medical records of patients who were diagnosed with interstitial pregnancy and received MTX as first-line treatment between January 2003 and July 2014 at CHA Gangnam Medical Center. The treatment success rates and subsequent pregnancy outcomes were examined. RESULTS: Ninety-seven patients were diagnosed with interstitial pregnancy between January 2003 and July 2014. Of them, 38 initially received MTX treatment. The diagnosis was made at a median of 6+3 weeks (5+0 to 11+3 weeks). Thirty patients received a systemic MTX injection, while the other 8 received a local MTX injection. Systemic treatment composed of an 8-day alternating MTX regimen, single-dose regimen, or high-dose regimen (100 mg/m2 + 200 mg/m2 intravenously over 12 hours). The local injection consisted of a direct MTX injection into the gestational sac with or without systemic MTX injection. Twenty-one patients (55.3%) were successfully treated with MTX. However, MTX therapy failed in 17 patients (44.7%), who required surgery. Mode of MTX treatment was the only predictive variable of MTX treatment success (P=0.039). Treatment success was seen in 7 of 8 patients (87.5%) in the local MTX group vs. 14 of 30 patients (46.7%) in the systemic MTX group. After treatment, 13 patients attempted a successive pregnancy; of them, 10 patients had a confirmed clinical pregnancy and healthy live birth. CONCLUSION: Combined MTX treatment including a local injection might be an initial approach to the treatment of interstitial pregnancy.

Dilatation and curettage is more accurate than endometrial aspiration biopsy in early-stage endometrial cancer patients treated with high dose oral progestin and levonorgestrel intrauterine system / 부인종양

OBJECTIVE: To determine whether less invasive endometrial (EM) aspiration biopsy is adequately accurate for evaluating treatment outcomes compared to the dilatation and curettage (D&C) biopsy in early-stage endometrial cancer (EC) patients treated with high dose oral progestin and levonorgestrel intrauterine system (LNG-IUS). METHODS: We conducted a prospective observational study with patients younger than 40 years who were diagnosed with clinical stage IA, The International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid adenocarcinoma and sought to maintain their fertility. The patients were treated with medroxyprogesterone acetate 500 mg/day and LNG-IUS. Treatment responses were evaluated every 3 months. EM aspiration biopsy was conducted after LNG-IUS removal followed D&C. The tissue samples were histologically compared. The diagnostic concordance rate of the two tests was examined with κ statistics. RESULTS: Twenty-eight pairs of EM samples were obtained from five patients. The diagnostic concordance rate of D&C and EM aspiration biopsy was 39.3% (κ value=0.26). Of the seven samples diagnosed as normal with D&C, three (42.8%) were diagnosed as normal by using EM aspiration biopsy. Of the eight samples diagnosed with endometrioid adenocarcinoma by using D&C, three (37.5%) were diagnosed with endometrioid adenocarcinoma by using EM aspiration biopsy. Of the 13 complex EM hyperplasia samples diagnosed with the D&C, five (38.5%) were diagnosed with EM hyperplasia by using EM aspiration biopsy. Of the samples obtained through EM aspiration, 46.4% were insufficient for histological evaluation. CONCLUSION: To evaluate the treatment responses of patients with early-stage EC treated with high dose oral progestin and LNG-IUS, D&C should be conducted after LNG-IUS removal.

Assessment of Breast Cancer Patients' Knowledge and Decisional Conflict Regarding Tamoxifen Use

Breast cancer is the most common type of female cancer. Tamoxifen, a selective estrogen receptor modulator, is widely used to decrease breast cancer recurrence and mortality among patients. However, it also increases the risk of endometrial cancer. This study aimed to assess knowledge and decisional conflict regarding tamoxifen use. Between June and October 2014, breast cancer patients using tamoxifen were consecutively screened and requested to complete a survey including the EQ-5D, Satisfaction with Decision Scale (SWD), Decisional Conflict Scale (DCS), and a self-developed, 15-item questionnaire measuring tamoxifen-related knowledge. The study sample comprised 299 patients. The mean total knowledge score was 63.4 of a possible 100.0 (range, 13.3-93.3). While 73.9% of the participants knew that tamoxifen reduces the risk of breast cancer recurrence, only 57.9% knew that the drug increases endometrial cancer risk. A higher education level (> or =college) was associated with a higher, total knowledge score (beta = 4.291; P = 0.017). A higher knowledge score was associated with a decreased DCS score (beta = -0.366; P < 0.001). A higher SWD score was also associated with decreased decisional conflict (beta = -0.178; P < 0.001). In conclusion, the breast cancer patients with higher levels of tamoxifen-related knowledge showed lower levels of decisional conflict regarding tamoxifen use. Clinicians should provide the exact information about tamoxifen treatment to patients, based on knowledge assessment results, so as to aid patients' decision-making with minimal conflict.

Evaluation of risk factors of vaginal cuff dehiscence after hysterectomy

OBJECTIVE: The purpose of this study was to evaluate risk factors of vaginal cuff dehiscence or evisceration according to the type of operation. METHODS: Medical records of 604 women who underwent hysterectomies at Korea University Anam Hospital between June 2007 and June 2011 were reviewed. They were allocated to six groups. The six types of hysterectomies included robotic hysterectomy (n = 7), robotic radical hysterectomy and node dissection (RRHND, n = 9), total laparoscopic hysterectomy (TLH, n = 274), laparoscopy assisted vaginal hysterectomy (LAVH, n = 238), laparoscopic radical hysterectomy and node dissection (n = 11), and abdominal radical hysterectomy (ARH, n = 63). The characteristics and outcomes of each groups were compared. RESULTS: There was no difference in the characteristics of patients between 6 groups. In total of 604 hysterectomies, 3 evisceration (0.49%) and 21 dehiscences (3.47%) occurred. Evisceration were found in RRHND (1/9, 11.1%), TLH (1/276, 0.36%), and ARH (1/63, 1.56%). Dehiscences occurred in TLH (15/274, 5.42%), LAVH (4/238, 1.68%), and ARH (2/63, 3.17%). In 169 cases of TLH with intra-corporeal continuous suture, 1 evisceration and 4 dehiscences occurred, whereas 11 dehiscences occurred in 105 TLH cases with vaginal continuous locking suture (2.96% vs. 10.47%, P = 0.02). CONCLUSION: The incidence of vaginal cuff dehiscenceand eviscerationwas significantly higher in TLH than LAVH. The intra-corporeal cuff suture was superior to the vaginal suture to prevent the vaginal cuff complications in TLH.

The Effect of Body Mass Index on Survival in Advanced Epithelial Ovarian Cancer

Controversy remains regarding the effect of obesity on the survival of patients with ovarian cancer in Asia. This study examined the impact of obesity on the survival outcomes in advanced epithelial ovarian cancer (EOC) using Asian body mass index (BMI) criteria. The medical records of patients undergoing surgery for advanced (stage III and IV) EOC were reviewed. Statistical analyses included ANOVA, chi-square test, Kaplan-Meier survival and Cox regression analysis. Among all 236 patients, there were no differences in overall survival according to BMI except in underweight patients. In a multivariate Cox analysis, surgical optimality and underweight status were independent and significant prognostic factors for survival (HR, 2.302; 95% CI, 1.326-3.995; P=0.003 and HR, 8.622; 95% CI, 1.871-39.737; P = 0.006, respectively). In the subgroup of serous histology and optimal surgery, overweight and obese I patients showed better survival than normal weight patients (P = 0.012). We found that underweight BMI and surgical optimality are independent risk factors for the survival of patients with advanced ovarian cancer. High BMI groups (overweight, obese I and II) are not associated with the survival of advanced EOC patient. However, in the subgroup of EOC patients with serous histology and after optimal operation, overweight and obese I group patients show better survival than the normal weight group patients.

Candidates for Tumor Markers of Cervical Cancer Discovered by Proteomic Analysis

Cervical cancer is the second most common gynecological cancer among Korean women. While nationwide screening program has developed, the pathogenesis of cervical cancer is unknown. The aim of this study was to compare the protein expression profiles between cervical squamous carcinomas and normal cervical tissues in order to identify proteins that are related to the cancer. Three cervical cancer tissue samples and three normal cervical tissue samples were obtained and protein expression was compared and was identified in the samples with the use of matrix assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF-MS). A total of 20 proteins that showed up-regulated expression in the cervical cancer tissue samples were selected and identified. Seven proteins were matched to allograft inflammatory factor 1 (AIF-1), actine-like protein 2 (ALP2), brain type fatty acid-binding protein (B-FABP), NCK adaptor protein 1 (NCK-1), islet cell autoantigen 1 (ICA69), cationic trypsinogen (PRSS1), and cyclin-dependent kinase 4 (CDK4), but the remaining 13 proteins were unidentifiable. After confirmation by RT-PCR, Western blotting and immunohistochemistry, we found that B-FABP, NCK-1, and CDK4 were related to the pathogenesis of cervical cancer. These proteins are suggested as candidates of new pathological tumor markers for cervical cancer.

Ovarian Hyper-Response to Administration of an GnRH-Agonist Without Gonadotropins

Several case reports have indicated that a small subgroup of patients may develop ovarian hyperstimulation following the administration of gonadotropin-releasing hormone agonists (GnRHa) without gonadotropins. However, since only few such cases have been published, it is unclear what course to follow in subsequent cycles after ovarian hyperstimulation in the first cycle using only GnRHa. A 33-yr-old woman was referred to in vitro fertilization for oocyte donation. A depot preparation (3.75 mg) of tryptorelin without gonadotropins induced ovarian multifollicular enlargement with high estradiol level, and was followed by human chorionic gonadotropin administration and oocyte retrieval. In a subsequent cycle of the same patient, a low dose of tryptorelin (0.05 mg) did not induce ovarian hyperstimulation, and resulted in clinical pregnancy. This report shows potential management of ovarian hyperstimulation following the administration of GnRHa without gonadotropins.

Endometrial mullerian adenosarcoma after toremifene treatment in breast cancer patients: a case report / 부인종양

Toremifene is an anti-estrogen which has been shown to be effective in the treatment of breast cancer, and is thought to be a less uterotrophic agent than tamoxifen. The risk assessment concerning endometrial cancer has been inconclusive because of its rare use up to the mid-1990s. We report a case of an adenosarcoma, which is a very rare type of uterine malignancy, after toremifene treatment for 5 years in a breast cancer patient. After 1 year of toremifene use, the patient had a benign Mullerian adenofibroma. After an additional 4 years of toremifene treatment, the endometrial polypoid lesion was transformed into a Mullerian adenosarcoma. Although toremifene is a promising anti-estrogenic agent in the treatment of breast cancer patients, clinicians should not neglect the possibility of a uterine malignancy.

A Case of Pregnancy in Essential Thrombocythaemia with Low dose Aspirin Treatment / 대한주산의학회잡지

Essential thrombocythaemia (ET) is a chronic myeloproliferative disorder characterized by markedly elevated platelet count in the peripheral blood due to an excessive proliferation of bone marrow megakaryocytes. The pregnancy outcome among patients with ET is mostly successful but adverse outcome due to thrombotic and bleeding complications is a matter of concern: miscarriage, intrauterine growth retardation, abruptio placenta, intrauterine fetal death and preterm delivery. Various treatments such as acetylsalicylic acid, hydroxyurea, anagrelide, heparin, interferon alpha and plateletpheresis have been proposed to improve the pregnancy outcome. We report a case of pregnant woman in condition of ET who succeeded in normal vaginal delivery without specific obstetric complications after low dose aspirin therapy during pregnancy.