Disseminated Peritoneal Leiomyomatosis with Atypical Features and Comorbid Uterine STUMP: a Case Report and Review of the Literature

Disseminated peritoneal leiomyomatosis (DPL) is a very rare benign disease, characterized by multiple solid subperitoneal or peritoneal smooth muscle nodules in abdominopelvic cavity and malignant transformation is extremely rare. Also, uterine smooth muscle tumors of unknown malignant potential (STUMP) is a rare tumor, which is regarded as subclassification in uterine smooth muscle tumors between benign and malignant criteria. Pathogenesis of DPL is uncertain, but increasing evidence of iatrogenic cause including laparoscopic myomectomy has been reported.We report a case of a 28-year-old female with previous history of laparoscopic myomectomy diagnosed with DPL with atypical feature and concurrent uterine STUMP using computed tomography (CT) and magnetic resonance imaging (MRI), as well as present a review of the literature.

Human papillomavirus test for prediction of recurrent and residual disease after treatment for cervical intraepithelial neoplasia / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate high-risk (HR) HPV DNA test to predict recurrence/residual disease in patients treated for CIN (cervical intraepithelial neoplasia). METHODS: Four hundred and fifty-two patients treated with LLETZ (large loop excision of the transformation zone) were followed by HR HPV DNA test, cytology and colposcopy. The sensitivity, specificity and diagnostic odds ratios in predicting recurrence/residual disease were compared to those of cytology and HPV DNA test. RESULTS: Fourteen patients (3.1 %) developed recurrent/residual disease, during follow up. Of these women, 7 were diagnosed at the time of recurrence with a CIN 1 lesion, 5 with a CIN 2 lesion, and 2 with a CIN 3 lesion. The sensitivity and specificity of the HPV DNA test were 92.9% (CI 68.5%, 98.7%) and 75.3% (71.1%, 79.1%). The sensitivity and specificity of the cytology were 71.4% (45.4%, 88.3%) and 92.5% (89.6%, 94.6%), respectively. The likelihood ratio of a positive and negative HPV DNA test were 3.77 (3.03, 4.69) and 0.09 (0.01, 0.63). And the likelihood ratio of a positive and negative cytology were 9.48 (5.95, 15.11) and 0.31 (0.13, 0.71). The accuracy of cytology and HPV DNA test were 94.7% and 78.3%. The sensitivity and specificity of the combination test (PAP and/or HPV DNA test) were 92.9% (68.5%, 98.7%) and 73.1% (68.7%, 77.0%). The likelihood ratio of a positive and negative combination test were 3.45 (2.79, 4.26) and 0.10 (0.01, 0.65). CONCLUSION: Cytology remains the base in the follow up after of CIN. HPV DNA test increase the sensitivity of cytology. Negative HPV test can rule out recurrent/residual disease.

Annual report of gynecologic cancer registry program in Korea: 1991~2004 / 대한산부인과학회지

Korean Society of Obstetrics and Gynecology estimates the number of new gynecologic cancer cases and deaths expected in Korea in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the Gynecologic Cancer Registry Program every one or two years. Recently, gynecologic cancer registry gathering clinical data in 2005~2006 is in progress. In this article, we provide an overview of cancer statistics, including recent trends in gynecologic cancer incidence, mortality, and survival rates from 1991 through 2004.

Management of Regional Lymph Nodes in Localized Vulvar Carcinoma / 대한방사선종양학회지

PURPOSE: To evaluate the impact of postoperative radiotherapy on loco-regional failure in patients with vulvar carcinoma and to determine the treatment strategy for inguinal lymph nodes. MATERIALS AND METHODS: Sixty-six patients who received treatment for primary vulvar carcinoma at Seoul National University Hospital, from October 1979 through June 2004, were retrospectively analyzed. Sixteen patients were excluded from the analysis due to the following reasons: distant metastases in two patients; palliative intent for six patients; previous radiotherapy given to the pelvis in three patients; follow-up loss after surgery for four patient; insufficient medical records for one patient. Of 50 eligible patients, 35 were treated with surgery alone (S), ten were treated with surgery followed by radiotherapy (S+RT), and five were treated with radiotherapy alone. RESULTS: The 5-year overall survival (OS) and disease-free survival (DFS) rates of all patients were 91% and 78%, respectively. Twelve patients (26%) experienced treatment failures and the sites of initial failure were as follows: a primary site in eight patients; regional lymph nodes in three patients; the lung in one patient. Although risk factors for failure were more common in the S+RT group than the S group of patients (p<0.05), the DFS rates were similar for the two groups (5-year DFS rates, 78% vs. 83%, p=0.66). The incidences of occult lymph node metastases was 10%. Ten of 31 patients with clinically negative lymph nodes did not received inguinal lymph node dissection, but no patient experienced regional failure. CONCLUSION: Postoperative radiotherapy may have a potential benefit for patients with risk factors for failure. The omission of inguinal dissection or elective radiotherapy to the inguinal lymph nodes may be considered in low-risk patients with clinically negative lymph nodes.

Analysis of clinical characteristics and prognosis in patients with recurrent cervical cancer / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to analyze the clinical course and prognosis in patients with recurrent cervical cancer. METHODS: Between January 1999 and December 2003, sixty-three patients were diagnosed as recurrent cervical cancer. The data for clinical characteristics and survival were analyzed retrospectively. Survival after recurrence (SAR) according to prognostic factors was evaluated using Kaplan-Meier analysis with log-rank test. Independent prognostic factors were identified by use of Cox regression model. RESULTS: The most common stage and age group of the patients were FIGO stage Ib (38.1%) and age between 40 and 49 (39.7%) respectively. Distant metastases were present in 29 patients (46.0%) and the most common site was para-aortic lymph node. Median disease-free survival before the recurrence of cervical cancer was 19 months (95% CI = 9.5 - 28.5). Median SAR was 24 months (95% CI = 17.4 - 30.6) and 5-year survival rate after recurrence was 20.0%. In univariate analysis of the prognostic factors, age, FIGO stage, primary treatment with surgery and number of recurred site were statistically significant. But, multivariate analysis showed that only FIGO stage and the number of recurrent site had prognostic significance. CONCLUSION: FIGO stage and number of recurrent site may be independent prognostic factors for the survival in patients with recurrent cervical cancer.

Clinical characteristics of ovarian cancer patients who underwent enterostomy / 대한산부인과학회지

OBJECTIVE: The aim of this study was to examine the clinical characteristics of patients with ovarian cancer who underwent enterostomy. METHODS: Via medical record review, we obtained clinical information of 51 ovarian cancer patients who underwent enterostomy in our hospital, from 1990 to 2006. We compared the clinical characteristics according to the indication of enterostomy: primary cytoreduction (PC), secondary cytoreduction (SC), and palliative only (PO). In addition, we investigated the correlations among clinical characteristics to find prognosticators. RESULTS: Patients were older (P=0.061), had less upper gastrointestinal symptoms (P=0.000), underwent colostomy rather than ileostomy (P=0.037), and received more postoperative chemotherapy (P=0.000) according to the following order: PC, SC, PO groups. Older patients had more postoperative complications (P=0.035). In the PC group, older patients had less chance of optimal debulking (P=0.020). In the PO group, preoperative gastrointestinal symptoms were associated with the type of enterostomy. CONCLUSIONS: Clinical characteristics of patients were different according to the indication of enterostomy. Careful examination of clinical characteristics and gastrointestinal symptoms might be helpful to predict the postoperative quality of life.

Recurrent aggressive angiomyxoma of vulva: A case report / 대한산부인과학회지

Aggressive angiomyxoma (AAM) is a rare soft tissue tumor composed of scattered spindle cells and abundant vessels embedded in a myxoid matrix. It is a benign slow growing tumor, but locally infiltrative and have a propensity of recurrence. We described the case of a recurrent aggressive angiomyxoma of vulva in a 47-year old female patient. She had a history of vulvar excision at local clinic 2-years ago, and visited our institute with a complaint of pain associated vulvar mass. Wide local excision with postoperative adjuvant GnRH agonist therapy was done according to pathologic report which revealed positive resection margin with estrogen/progesterone receptors positive. She is now free of disease during 15 months of follow up. We report the case with a brief review of the literature.

One-year follow-up outcomes of tension-free vaginal tape (TVT) procedure for treatment of stress urinary incontinence / 대한산부인과학회지

OBJECTIVE: To evaluate one-year outcomes of tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence (SUI). METHODS: From 2002 to 2005, all patients with stress urinary incontinence undergoing the TVT procedure were enrolled in this retrospective study. All cases were diagnosed as SUI by the evidences in history, physical examination, and urodynamic study. Outcomes and post-operative complications were investigated from review of medical records and interview during post-operative follow-up. RESULTS: Totally 164 cases were enrolled in this study. The success rates (cure or improved) of two-month and one-year after the TVT procedure were 94.5% and 87.9%, and the failure rates were 5.5% and 3.0%, respectively. The follow-up loss rate in one-year was 9.1%. There was no serious complication related to the procedure in one-year follow-up. CONCLUSION: This preliminary report indicates that the TVT procedure is a safe treatment modality for female SUI. Further investigation with long term follow-up is required to estimate cumulative success rate and late complications.

Pattern of care: epithelial ovarian cancer in case of incomplete previous surgery / 부인종양

OBJECTIVE: A significant number of patients with ovarian cancer are referred to tertiary center after inadequate staging operation. The purpose of this study was to evaluate the impact of pattern of care, including restaging operation or chemotherapy in these patients. METHODS: We conducted a retrospective analysis of patients with epithelial ovarian cancer (n=29) or borderline tumor (n=15) who were inadequately staged elsewhere at the time of initial surgery between April 1996 and March 2006. RESULTS: In the patients with ovarian cancer, restaging operation was performed in 65.5% (19/29), and primary chemotherapy in 24.1% (7/29). Older age and higher parity was noted in the restaged group, however, it was statistically insignificant. In the restaged group, 26.3% (5/19) were upstaged due to residual tumors. Presence of residual tumor was not associated with histologic type and grade of tumor. Six patients (31.6%) without residual tumor escaped adjuvant chemotherapy. During median 50 months follow up, 13.8% (4/29) of patients with ovarian cancer recurred. There was no difference in recurrence rate according to whether a restaging operation was performed. However, residual tumor status was significantly associated with recurrence rate (60% vs 0%). Restaging operation was undergone in 46.7% (7/15) of patients with borderline tumors and there were no recurrence or residual tumor in patients with borderline tumors. CONCLUSION: It is suggested that restaging operation could reveal residual tumors which are important prognostic factor in predicting recurrence. Nonetheless, Restaging operation seems to have no impact on the prognosis of ovarian cancer.

Accuracy of frozen section diagnosis for ovarian tumors according to histologic type and malignant potential / 부인종양

OBJECTIVE: The purpose of this was to evaluate accuracy of frozen section diagnosis for ovarian tumors according to histologic type and malignant potential. METHODS: We compared the frozen section and final diagnosis of patients with ovarian tumors from April 2001 to April 2006. Of these 1138 cases, 628 cases (55.2%) were epithelial ovarian tumors. Benign, borderline, and malignant epithelial tumors were 380 (60.5%), 87 (13.9%), and 161 (25.6%) cases. The accuracy of frozen section diagnosis was analyzed according to histologic type and malignancy potential. RESULTS: The overall accuracy of frozen section diagnosis was 93.9%. The accuracy for benign, borderline, and malignant tumors were 93%, 92%, and 98%, respectively. The accuracy of frozen section diagnosis was significantly low in mucinous tumors and borderline malignant tumors. However the borderline malignancy was the only independent factor associated with the inaccuracy of frozen section diagnosis (OR: 12.2, 95% CI: 6.5-23.1). The sensitivity for immature teratoma was as low as 63.6%. CONCLUSION: Our data shows that the accuracy is low in mucinous tumors, borderline tumors, and immature teratomas and the borderline malignancy is independent factor associated with inaccuracy of frozen section diagnosis.

Interleukin-1 Beta -511 Polymorphism and Risk of Cervical Cancer

Cervical cancer is almost invariably associated with infection by human papillomavirus. It is believed that the host genetic factors such as inflammation-induced cytokines may play a role in cervical carcinogenesis. The IL1B gene, encoding IL-1beta cytokine, contains several single nucleotide polymorphisms. One of them which is in the positions -511 (C-T) related with promoter region has been associated with increased IL-1beta production and with increased risk of developing a number of inflammatory diseases and gastric carcinoma. We assessed the association between the IL1B -511 polymorphism and cervical cancer risk in a hospital-based case-control study among 546 Korean women (182 cases; 364 age-matched controls). The allele frequencies of the case subjects (C, 0.42; T, 0.58) were not significantly different from those of control subjects (C, 0.43; T, 0.57). Control subjects were in Hardy-Weinberg equilibrium. The carriers with -511 C/T or T/T genotypes were at higher risk of cervical cancer with odds ratio of 2.42 (95% CI 1.31-4.46, p<0.005). However, there was no difference of cervical cancer risk between C/T heterologous genotypes and T/T homologous genotypes. In conclusion, in Korean population, IL1B -511 C/C genotypes were significantly associated with a decreased risk of cervical cancer.

Overexpression of hTERT and c-erbB-2 are correlated in ovarian epithelial cancer / 부인종양

OBJECTIVE: It is still unclear how the abnormal hTERT expression is involved in the process of ovarian carcinogenesis. A recent report demonstrated that the introduction of c-erbB-2 could efficiently induce tumorigenicity of cells with the transfection of SV40 large T antigen and hTERT. It is designed to find correlation between overexpression of hTERT and c-erbB-2 in ovarian carcinogenesis. METHODS: Using immunohistochemistry, we tested whether overexpression of hTERT and c-erbB-2 were associated in ovarian cancer. Immunohistochemical staining of hTERT and c-erbB-2 was done in 63 cases of ovarian cancer. Overexpression of hTERT and c-erbB-2 were correlated to clinicopathological variables. RESULTS: Overexpression of hTERT was found in 7 (11.1%) of cases, whereas overexpression of c-erbB2 was founded in 3 (4.8%) of cases. It was found that overexpression of hTERT and c-erbB-2 were significantly correlated (p=0.03). Neither overexpression of hTERT nor that of c-erbB-2 was associated with any of clinicopathological variables, such as stage, grade, and histology. CONCLUSION: Although the significant correlation between hTERT and c-erbB-2 was found, the low frequency of overexpression of hTERT and c-erbB-2 suggests that cooperation of hTERT and c-erbB-2 may be minor mechanism of ovarian carcinogenesis.

Clinical analysis of the effect to survival by FIGO stage and surgical treatment combined with chemotherapy in patients with pseudomyxoma peritonei / 부인종양

OBJECTIVE: The purpose of this study was to compare the survival of patients with pseudomyxoma peritonei (PMP) according to the modalities of treatment and find out the prognostic factors by evaluating clinical variables. METHODS: Thirty one patients were treated at Seoul National University Hospital between May 1995 and May 2005. The clinical data were collected retrospectively and all charts were reviewed. Kaplan-Meier survival analyses with low-rank test were performed for the comparison of survival according to clinical variables, and univariate and multivariate Cox regression analyses were performed for finding out the prognostic factors of PMP. RESULTS: The mean age at diagnosis was 60.9 years and the mean survival (MS) was 25 months. The recurrence rate was 46.7 % and the disease free survival (DFS) till recurrence was 22.6 months. The prognostic factors affecting DFS were histology, FIGO stage, ascites, CA 125, residual disease in 1st and last operations by univariate analyses, but only FIGO stage was the statistically significant prognostic factor by multivariate analysis. Surgical treatment combined with chemotherapy (intraperitoneal or adjuvant) improved MS more than surgical treatment alone by univariate analysis. CONCLUSION: FIGO stage is a prognostic factor that can predict the DFS in patients with PMP. Histology, CA 125, ascites, residual disease may be probably prognostic factors associated with DFS. Surgical treatment combined with chemotherapy is more effective than surgical treatment alone for the treatment of PMP.

Overexpression of hTERT and c-erbB-2 are correlated in ovarian epithelial cancer / 부인종양

OBJECTIVE: It is still unclear how the abnormal hTERT expression is involved in the process of ovarian carcinogenesis. A recent report demonstrated that the introduction of c-erbB-2 could efficiently induce tumorigenicity of cells with the transfection of SV40 large T antigen and hTERT. It is designed to find correlation between overexpression of hTERT and c-erbB-2 in ovarian carcinogenesis. METHODS: Using immunohistochemistry, we tested whether overexpression of hTERT and c-erbB-2 were associated in ovarian cancer. Immunohistochemical staining of hTERT and c-erbB-2 was done in 63 cases of ovarian cancer. Overexpression of hTERT and c-erbB-2 were correlated to clinicopathological variables. RESULTS: Overexpression of hTERT was found in 7 (11.1%) of cases, whereas overexpression of c-erbB2 was founded in 3 (4.8%) of cases. It was found that overexpression of hTERT and c-erbB-2 were significantly correlated (p=0.03). Neither overexpression of hTERT nor that of c-erbB-2 was associated with any of clinicopathological variables, such as stage, grade, and histology. CONCLUSION: Although the significant correlation between hTERT and c-erbB-2 was found, the low frequency of overexpression of hTERT and c-erbB-2 suggests that cooperation of hTERT and c-erbB-2 may be minor mechanism of ovarian carcinogenesis.

Clinical analysis of the effect to survival by FIGO stage and surgical treatment combined with chemotherapy in patients with pseudomyxoma peritonei / 부인종양

OBJECTIVE: The purpose of this study was to compare the survival of patients with pseudomyxoma peritonei (PMP) according to the modalities of treatment and find out the prognostic factors by evaluating clinical variables. METHODS: Thirty one patients were treated at Seoul National University Hospital between May 1995 and May 2005. The clinical data were collected retrospectively and all charts were reviewed. Kaplan-Meier survival analyses with low-rank test were performed for the comparison of survival according to clinical variables, and univariate and multivariate Cox regression analyses were performed for finding out the prognostic factors of PMP. RESULTS: The mean age at diagnosis was 60.9 years and the mean survival (MS) was 25 months. The recurrence rate was 46.7 % and the disease free survival (DFS) till recurrence was 22.6 months. The prognostic factors affecting DFS were histology, FIGO stage, ascites, CA 125, residual disease in 1st and last operations by univariate analyses, but only FIGO stage was the statistically significant prognostic factor by multivariate analysis. Surgical treatment combined with chemotherapy (intraperitoneal or adjuvant) improved MS more than surgical treatment alone by univariate analysis. CONCLUSION: FIGO stage is a prognostic factor that can predict the DFS in patients with PMP. Histology, CA 125, ascites, residual disease may be probably prognostic factors associated with DFS. Surgical treatment combined with chemotherapy is more effective than surgical treatment alone for the treatment of PMP.

A Case of Retroperitoneal Liposarcoma Presenting as Pelvic Mass / 대한산부인과학회지

Liposarcoma is the most common soft tissue sarcoma in adults and accounts for 9.8% to 16% in all soft tissue sarcomas. The common sites include limbs, buttocks, and retroperitoneum, et al. The early diagnosis of retroperitoneal liposarcoma may be difficult because of due to the late onset of symptoms and the tumors are frequently noted in a large size with the involvement of adjacent structures. Surgical therapy remains the most effective modality for the treatment of retroperitoneal liposarcoma. But, complete surgical resection of these tumors is often challenging and, at times, may be impossible. So, adjuvant radiation therapy is necessary for the improvement of prognosis in many cases. We report a case of retroperitoneal liposarcoma which was treated with complete surgical resection followed by adjuvant radiation therapy.

Mixed Large Cell Neuroendocrine Tumor and Adenocarcinoma of the Ovary / 대한산부인과학회지

Neuroendocrine tumor is a very heterogenous group arising from the neuroendocrine cells. Especially, large cell neuroendocrine tumor of the ovary is a extremely rare aggressive neoplasm, characteristically arising in association with a surface epithelial tumor. This report describes a mixed type of large cell neuroendocrine carcinoma and adenocarcinoma of the ovary. A 63-year old woman presented with abdominal distension and discomfort underwent staging laparotomy under the impression of ovarian cancer. The operation revealed an small ovarian mass with invasion of multiple region in peritoneal cavity by the tumor. Immunohistochemical and ultrastructural analysis confirmed the neuroendocrine nature of the tumor. The adenocarcinoma in this case is mixture of mucinous and endometrioid type. A diagnosis of stage IIIc mixed large cell neuroendocrine tumor and adenocarcinoma of the ovary was rendered. She is subsequently being treated with Paclitaxel and Carboplatin combination chemotherapy.

Clinical efficacy of diagnostic laparoscopy in the diagnosis of gynecologic disorders / 대한산부인과학회지

OBJECTIVE: Diagnostic laparoscopy had been frequently used in female infertility. In the present study, we assessed the change of indications and clinical efficacy of diagnostic laparoscopy in gynecologic disorders. METHODS: A clinical analysis of the recent 8,335 cases of diagnostic laparoscopy from the April, 1994 to August, 2005 was performed and compared with the previous 11,665 cases from June, 1974 to March, 1994. We compared the diagnoses after diagnostic laparoscopy and those after pelvic examination or pelvic ultrasound, and checked the final pathologic diagnoses after operation if performed. RESULTS: Infertility was the most common indication in earlier period, however, pelvic mass (29.7%), endometriosis (22.1%), and chronic pelvic pain (14.7%) became the major indications of diagnostic laparoscopy in gynecologic disorders in recent period. Diagnoses made by clinical examination or imaging modalities were changed after performing diagnostic laparoscopy in 4.9% of the patients, and the complication rate was 0.24% in this study. CONCLUSION: Our study reveals that diagnostic laparoscopy is a feasible and safe diagnostic procedure based on out patient department, and it can decrease misdiagnosis and unnecessary operative procedure, and therefore, can be used as a best guideline for individualized treatment of gynecologic disorders.

Cyclooxygenase expressions and response to radiation therapy in uterine cervix cancer / 부인종양

OBJECTIVE: The aim of this study is to clarify the relationship between COX expressions and radioresistance in cervical cancer. METHODS: Patients with cervical cancer treated by primary radiotherapy were selected from the tumor registry of our institution. According to the response to radiotherapy during and after a month of radiation, poor responder and good responder was defined. Immunohistochemical staining was performed by the ABC method using formalin-fixed, paraffin-embedded tissue sections and monoclonal anti-COX-1,2 antibodies. Correlation of COX expression and response to radiation was analyzed. Cell lines derived from human cervical tumors were used: HeLa, HT3, and C33A. Using western blot, COX-1,2 expressions were identified in each cell line. The sensitivity of the cervix cancer cells to radiation was measured using a clonogenic assay. RESULTS: COX-1 and COX-2 expressions were higher in poor responders than good responders. The difference of COX-1 expression between two groups had marginal statistical significance (p=0.099, Fisher's exact test) and COX-2 expression was significantly higher in poor responders (p=0.034, Fisher's exact test). In the clonogenic assay, survival fraction of HeLa and HT-3 cell lines, which have COX-1 and COX-2 activity, was significantly higher than C33A cell line which has no COX activity (p<0.001). CONCLUSION: Our results suggest that the expression of COX in cervical cancer might be deeply associated with the effect of radiation therapy.

Lack of Association between L-myc Single Nucleotide Polymorphism and Cervical Cancer Susceptibility and Invasiveness in Korean Women / 대한산부인과학회지

OBJECTIVE: The aim of this investigation was to analyze the association between a single nucleotide polymorphism (SNP) in L-myc gene (T3109G) and the cervical cancer susceptibility or invasiveness in Korean women. METHODS: The blood samples of 231 cervical cancer patients and 332 non-cancer control subjects who managed at Seoul National University Hospital from 1999 to 2002 were collected. Polymorphism in L-myc (T3109G) was determined using TaqMan method. Allele frequency and genotype distribution in the cervical cancer group were compared with those of the control group to determine whether this polymorphism elevates the susceptibility of Korean women to the cervical cancer. The relationship between this SNP and cancer invasiveness was also evaluated by collating clinicopathologic data of those in the cancer group, such as age, FIGO stage, histologic type, lymph node metastasis and parametrial invasion. RESULTS: In the cervical cancer group, the allele frequency of G was 47.6%, in the control group 48.5%, showing no significant difference (p=0.808). Similarly the genotypes with TG or GG showed no increased risk for the cervical cancer compared with TT genotype. A subgroup analysis of the clinicopathologic parameters in cancer group also showed no significant difference suggesting the lack of an association between SNP of the L-myc and the cervical cancer invasiveness. CONCLUSION: This study shows that Korean women with specific polymorphism in L-myc are neither more susceptible to develop the cervical cancer nor more vulnerable for the cancer progression.