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.

Clinical characteristics of patients with leiomyoma who undergo surgery after high intensity focused ultrasound (HIFU)

OBJECTIVE: We evaluated the clinical characteristics of patients who underwent surgery after high intensity focused ultrasound (HIFU) to treat uterine leiomyoma. METHODS: From June 2016 to September 2017, patients at our hospital who underwent HIFU to treat uterine leiomyoma prior to surgery were enrolled. All patients underwent pelvic magnetic resonance imaging (MRI) before and after HIFU. If 6 months had passed since the last pelvic MRI was performed, imaging was performed again before the operation. RESULTS: A total of 12 patients were analyzed. The median age was 45 (range, 28–51) years. The median body mass index was 24.9 (range, 18.1–29.2) kg/m2. The median size of the leiomyoma was 10.1 (range, 7.8–14.0) cm before HIFU, which changed to 8.75 (range, 5.9–14.8) cm after HIFU. The median size increased to 9.1 (range, 5.9–18.0) cm before the operation. Surgery was planned for several reasons, including an increase in the leiomyoma size (n=6), persistent symptoms (n=4), and newly developed lesion (n=2). The median interval between HIFU and surgery was 7 (range, 3–32) months. Ten of the 12 patients underwent laparoscopic surgery, while the others underwent laparotomy; 6 patients also underwent laparoscopic myomectomy, and 4 underwent hysterectomy. Histopathologic findings showed infarction-type necrosis surrounded by granulation tissue with the infiltration of lymphocytes and macrophages in all patients. CONCLUSION: Treatment of leiomyoma with operative procedures should be considered in selected patients with tumor size greater than 10 cm, multiple tumors, and persistent symptoms after HIFU treatment.

Patient Blood Management: Obstetrician, Gynecologist's Perspectives / 한양의대학술지

Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patient blood management (PBM). We will review to summarize the alternative measures and interventions used in bloodless surgery in the field of obstetrics and gynecology. In the obstetric field, PBM has been developed as an evolving evidence-based approach with a number of key goals: (i) to identify, evaluate, and manage anemia; (ii) reduce iatrogenic blood loss; (iii) optimize hemostasis; and (iv) establish decision thresholds for transfusion. Transfusion, mechanical method including balloon tamponade and uterine artery embolization, and intraoperative cell salvage were introduced for PBM. In the gynecologic field, PBM is not significantly different from that in the obstetric field. Preoperative managements include iron supplement, erythropoietin administration, autologous blood donation, and uterine artery embolization. Meticulous hemostasis, short operative time, hypotensive anesthetic techniques, hemodilution during operation, blood salvage and pharmacological agents were introduced to intraoperative management. Postoperative measures include meticulous postoperative monitoring of the patient, early detection of blood loss, reduction of blood sampling, appropriate use of hemopoiesis, normalization of cardio-pulmonary function and minimization of oxygen consumption. In conclusion, each obstetrician and gynecologist should be aware about the appropriate method for blood conservation and use in practice. A comprehensive approach to coordinating all members of the bloodless agent and surgical team is essential.

Preoperative diagnostic clues to ovarian pregnancy: retrospective chart review of women with ovarian and tubal pregnancy

OBJECTIVE: To analyze the preoperative diagnostic clues to ovarian pregnancy (OP). METHODS: This study conducted a retrospective chart review of 23 patients with OP and 46 patients with tubal pregnancy (TP) from October 1, 2003 to September 31, 2016 in Hanyang University Hospital. RESULTS: There were no significant differences in demographic and clinical characteristics between the two groups. The presence of an ectopic gestational sac and hemoperitoneum was significantly higher in the TP group (13.0% vs. 95.7%, P=0.000; 13.0% vs. 54.3%, P=0.001, respectively) in preoperative ultrasonogram. The OP group had more ruptured ectopic gestational sacs than the TP group (73.9% vs. 45.7%, P=0.039) in surgical findings. CONCLUSION: For the patients in whom a gestational sac is not detected in the uterus or the fallopian tubes, it is important to be aware of the possibility of OP and rupture of an ovarian gestational sac to promote early diagnosis and surgical intervention.

The Role of Steroid Sulfatase as a Prognostic Factor in Patients with Endometrial Cancer

PURPOSE: The aim of the study was to determine steroid sulfatase (STS) expression in endometrial cancer patients and its correlation with disease prognosis. MATERIALS AND METHODS: We conducted a retrospective study in 59 patients who underwent surgery with histologically confirmed endometrial cancer from January 2000 to December 2011 at Hanyang University Hospital. Immuno-histochemical staining of STS was performed using rabbit polyclonal anti-STS antibody. RESULTS: Sixteen of the 59 patients (27.1%) were positive for STS expression. Disease free survival (DFS) was 129.83±8.67 [95% confidence interval (CI): 112.84-146.82] months in the STS positive group (group A) and 111.06±7.17 (95% CI: 97.01-125.10) months in the STS negative group (group B) (p=0.92). Overall survival (OS) was 129.01±9.38 (95% CI: 110.63-147.38) months and 111.16±7.10 (95% CI: 97.24-125.07) months for the groups A and B, respectively (p=0.45). Univariate analysis revealed that FIGO stage and adjuvant therapy are significantly associated with DFS and OS. However, in multivariate analysis, FIGO stage and adjuvant therapy did not show any statistical significance with DFS and OS. STS was also not significantly associated with DFS and OS in univariate and multivariate analysis. CONCLUSION: STS expression was not significantly associated with DFS and OS, despite positive STS expression in 27% of endometrial cancer patients. Therefore, the role of STS as a prognostic factor in patients with endometrial cancer remains unclear and requires further research.

Safety of laparoscopically assisted vaginal hysterectomy for women with anterior wall adherence after cesarean section

OBJECTIVE: To evaluate the safety and surgical outcomes of laparoscopically assisted vaginal hysterectomy (LAVH) for women with anterior wall adherence after cesarean section. METHODS: We conducted a retrospective study of 328 women with prior cesarean section history who underwent LAVH from March 2003 to July 2013. The subjects were classified into two groups: group A, with anterior wall adherence (n=49); group B, without anterior wall adherence (n=279). We compared the demographic, clinical characteristics, and surgical outcomes of two groups. RESULTS: The median age and parity of the patients were 46 years (range, 34 to 70 years) and 2 (1 to 6). Patients with anterior wall adherence had longer operating times (175 vs. 130 minutes, P<0.05). There were no significant differences in age, parity, number of cesarean section, body mass index, specimen weight, postoperative change in hemoglobin concentration, or length of hospital stay between the two groups. There was one case from each group who sustained bladder laceration during the vaginal portion of the procedure, both repaired vaginally. There was no conversion to abdominal hysterectomy in either group. CONCLUSION: LAVH is effective and safe for women with anterior wall adherence after cesarean section.

Characteristics of thyroid incidentalomas detected by pre-treatment 18FFDG PET or PET/CT in patients with cervical cancer / 부인종양

OBJECTIVE: Considering the increased use of [18F]FDG PET or PET/CT, the clinical significance of thyroid incidentalomas is the subject of controversy. The aim of this study was to determine the incidence of malignancies associated with thyroid incidentalomas detected by pre-treatment PET or PET/CT in patients with cervical cancer. METHODS: We retrospectively reviewed the medical records of patients with cervical cancer who had thyroid incidentalomas detected by pre-treatment PET or PET/CT and were treated at our institute between January 2001 and December 2009. RESULTS: Of 327 patients who underwent pre-treatment PET or PET/CT, 33 patients had thyroid incidentalomas (10.1%) and 4 patients were diagnosed with thyroid malignancies by percutaneous needle aspiration (PCNA) or surgery. To put it concretely, of 33 patients with thyroid incidentaloma, 16 patients had a diffuse uptake and 17 patients had a focal uptake. Four of 17 patients with focal uptake were diagnosed with thyroid malignancies (23.5%). One patient with a focal uptake had an atypical cell based on PCNA, but did not undergo additional studies. The mean SUVmax of thyroid malignancies did not differ from that of benign thyroid diseases. CONCLUSION: Thyroid incidentalomas are frequently detected by pre-treatment PET or PET/CT in patients with cervical cancer. Focal uptake on PET or PET/CT has a high risk of thyroid cancer.

Collision of Three Histologically Distinct Endometrial Cancers of the Uterus

A collision tumor is defined by the presence of two separate masses in one organ, which are pathologically distinct. We described a 70-yr-old patient who complained of abnormal vaginal bleeding with a collision tumor of the uterine corpus. The patient received total hysterectomy, bilateral salphingo-oophorectomy, bilateral pelvic-paraaortic lymphadenectomy, omentectomy, and intraperitoneal chemotherapy. The uterine corpus revealed three separate masses, which were located at the fundus, anterior and posterior wall. Each tumor revealed three pathologically different components, which were malignant mixed mullerian tumor, papillary serous carcinoma, and endometrioid adenocarcinoma. Among these components, only the papillary serous carcinoma component invaded the underlying myometrium and metastasized to the regional lymph node. Adjuvant chemotherapy and radiation therapy were performed. The patient is still alive and has been healthy for the last 8 yr. We have reviewed previously reported cases of collision tumors which have occurred in the uterine corpus.

Malignant lymphoma originated from uterine cervix and extended to endometrium: A case report / 부인종양

Primary malignant lymphoma arising from the female genital tract is extremely rare. Most genital lymphomas arise in the Corpus and cervix of uterus and vagina. Patients usually present with bleeding, abdominal or pelvic discomfort but very infrequently the tumors are discovered as a result of a routine examination. We present a case of non-Hodgkin's malignant lymphoma originated from uterine cervix and extended to endometrium, and review the relevant literature.

Expressions of Leukemia Inhibitory Factor (LIF): Comparison of Normal Pregnancy and Recurrent Abortion / 대한산부인과학회잡지

OBJECTIVE: Successful implantation depends on a complex interaction between the developing blastocyst and the endometrium. Among the steroid hormones, growth factors, and cytokines which participate in preparing the uterus for implantation, leukemia inhibitory factor (LIF) plays an essential role in implantation. We compared the expression of LIF in normal pregnancies to that of recurrent abortions in placenta to elucidate whether spontaneous abortion and expression of LIF has correlation. METHODS: Placental tissues from normal pregnancies and recurrent abortions were fixed and embedded in paraffin. Standard immunohistochemical staining was used to identify LIF. RESULTS: LIF expressions on cytotrophoblast of recurrent abortion were lower than those of normal pregnancy. There were no expressions on syncytiotrophoblast and stroma in the both groups. In the decidua and gland, LIF was expressed in mild degree and there were no differences in LIF expression between normal pregnancy and recurrent abortion. CONCLUSION: LIF expression on cytotrophoblast of recurrent abortion was lower than that of normal pregnancy. LIF may provide paracrine and autocrine signals to both embryonic tissues and uterine epithelium during implantation. The dysfunction of LIF production may be a cause of the unexplained recurrent abortions.

Statistical Analysis of Twin Pregnancy for 10 Years (1993~2002) / 대한산부인과학회잡지

OBJECTIVE: Our purpose was to evaluate the clinical aspects of twin pregnancy and its outcome. METHODS: From January 1993 to December 2002, we reviewed the medical records of 249 cases of twin birth at least weighed 500 g or more and over 20 weeks of gestation among 14,273 deliveries at Hanyang University Hospital. Paired sample t test and linear regression test were used for statistical analysis. p<0.05 was defined significantly. RESULTS: The incidence of twin births was one in 59.6 birth, and the annual rate of twin births has increased since last 10 years (p<0.05). The predominant age group was 25-29 (47.0%) and mean age was 29.8 +/- 3.9 years old. According to parity, primipara (63.9%) was the most frequent. The predominant gestational age of twin births was 37-38 weeks (42.2%) and mean gestational weeks of twin births was 36.3 +/- 2.9 weeks. The ratio of spontaneous and iatrogenic twinning were 73.1% vs 26.9%. The cephalic-cephalic combination (49.8%) was the predominant presentation. The most common mode of twin delivery was cesarean section (76.5%) and its main indication was "elective" (33.5%). The mean interval between 1st and 2nd baby deliveries among normal spontaneous vaginal delivery was 6 minute 28 seconds. Both male group (43.0%) was predominant. The mean birth weights of 1st and 2nd baby were 2341 +/- 592 grams and 2200 +/- 594 grams respectively. No significant differences were seen in one minute and five minute Apgar scores between 1st and 2nd baby. The most common type of placental membrane was single placenta, two chorion, two amnion (40.6%). The most frequent maternal complication during pregnancy was anemia (41.8%), followed by preterm labor (39.0%) and preeclampsia (20.9%). The perinatal mortality rate was 50 per 1000 newborns and 2 cases (0.8%) of maternal death were encountered. The risk of intrauterine fetal death and abortion was 2.4% and 0.8% respectively. CONCLUSION: Recently, although the incidence of twin pregnancy has been increased, it has greater risks of obstetrical complications and higher perinatal mortality than singleton pregnancy. Therefore, further prospective studies of twin pregnancy are needed for counselling and effective management about perinatal prognosis.