Clinical experiences of the levonorgestrel-releasing intrauterine system in Korean women with adenomyosis / 대한산부인과내시경학회지

OBJECTIVE: To analyze the clinical experiences of patients who treated with levonorgestrel-releasing intrauterine system (LNG-IUS) for adenomyosis associated with dysmenorrhea and/or menorrhagia. METHODS: The LNG-IUS was inserted into 103 patients who were diagnosed with adenomyosis on ultrasound examination and suffered from dysmenorrhea or menorrhagia at CHA Gangnam Medical Center between January 2009 and December 2009. Symptomatic changes of dysmenorrhea and menorrhagia, side effects, and failure rates were evaluated, retrospectively. RESULTS: During the follow-up periods, dysmenorrhea was improved in 91.4% and menorrhagia was improved in 90.4% of patients. Most common side effects were prolonged vaginal spotting in 41 (39.8%), and expulsion of LNG-IUS in 32 (31.1%) patients. Six (5.7%) patients were premature removal of LNG-IUS and 9 (8.5%) patients were underwent hysterectomy. Overall 77 (74.8%) patients continued to use of LNG-IUS. CONCLUSION: The LNG-IUS is effective treatment option for management of dysmenorrhea and menorrhagia for patients with clinical diagnosis of adenomyosis. It seemed to be an alternative treatment method before hysterectomy.

Intraoperative intraperitoneal chemotherapy with cisplatin in epithelial ovarian cancer / 부인종양

OBJECTIVE: To assess retrospectively the feasibility of intraoperative intraperitoneal (IP) chemotherapy with cisplatin in epithelial ovarian cancer. METHODS: IP chemotherapy during optimal staging surgery was performed in 10 patients who were diagnosed with primary epithelial ovarian cancers between April 2008 and February 2011. Cisplatin (70 mg/m2 in 1 L normal saline solution) was administered in the abdominal cavity for 24 hours postoperatively and then adjuvant chemotherapy was started 2-4 weeks after surgery. Perioperative toxicity of the combined treatment was evaluated until the initiation of postoperative adjuvant chemotherapy. RESULTS: A total of 23 adverse events were observed in 9 of 10 patients (grade 1, 7; grade 2, 13; grade 3, 3; grade 4, 0). In descending order of frequency, adverse events affected the gastrointestinal system (n=14), hematologic system (n=6), pulmonary system (n=2), and genito-urinary system (n=1). The adverse events did not affect adjuvant systemic chemotherapy schedules. One patient experienced disease recurrence in the liver 16 months after surgery. The remaining 9 patients have been well controlled by chemotherapy and/or observation during the follow-up period of 4 to 39 months after surgery. CONCLUSION: Intraoperative IP chemotherapy with cisplatin during surgical procedures is considered feasible for the treatment of primary epithelial ovarian cancer. Further studies, including long-term, prospective and comparative trials, are needed to validate the efficacy of this combined therapy.

Single-port access total laparoscopic hysterectomy in women with history of previous abdominal surgery / 대한산부인과내시경학회지

OBJECTIVE: The aim of the present study was to evaluate the impact of previous abdominal surgery on surgical outcomes of single-port access (SPA) total laparoscopic hysterectomy (TLH). METHODS: We reviewed the medical records of 111 women who underwent SPA-TLH at the Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University between January 2010 and December 2010. Women were classified according to their history of previous abdominal surgery. RESULTS: Of 111 women undergoing SPA-TLH, 74 women (66.7%) without history of previous abdominal surgery and 37 women (33.3%) with history of previous abdominal surgery were classified. There was no significant difference in surgical outcomes including operative time, estimated blood loss, change in hemoglobin, uterine weight, perioperative complications, transfusion, and additional port insertion between two groups. CONCLUSION: In our experience, previous abdominal surgery has no significant impact on SPA-TLH.

A Case of Ovarian Microinvasive Mucinous Carcinoma and Co-existent Angiosarcoma

Primary ovarian angiosarcoma is very rare with only 27 cases reported so far in the medical literature. We report here on a rare case of ovarian microinvasive mucinous carcinoma that was coexistent with angiosarcoma in a 54-year-old woman. The tumor was a 26x19x10 cm-sized multilocular cystic mass with a 4x3 cm-sized solid hematoma-like nodule in the center. Microscopically, it was composed mostly of mucinous tumor of various grades from borderline to microinvasive carcinoma. The hematoma-like area turned out to be an angiosarcoma, composed of pleomorphic cells that formed slit-like spaces, spindle cells that formed short fascicles and anastomosing vascular channels with atypical endothelial cells. All these cells were positive for CD31, CD34 and factor VIII-related antigen. The patient developed peritoneal and pleural metastases, which were angiosarcoma and mucinous carcinoma, respectively. We believe this case is only the fourth example of an ovarian collision tumor of angiosarcoma and surface epithelial tumor.

The effectiveness of a single preoperative dose of misoprostol during laparoscopic myomectomy / 대한산부인과내시경학회지

OBJECTIVE: To evaluate the effectiveness of single preoperative dose of misoprostol to reduce intraoperative hemorrhage during laparoscopic myomectomy. METHODS: We reviewed retrospectively the medical records of 148 patients who underwent laparoscopic myomectomy in Gangnam CHA Medical Center between January 2007 and December 2009 by single surgeon. Among them, 46 patients used preoperative transrectal misoprostol. One hundred two patients underwent laparoscopic myomectomy in conventional method without any preoperative agents. RESULTS: The two groups were similar in baseline characteristics. There was no significant difference in mean blood loss (misoprostol group: 203.3+/-181.8 mL vs. no agent group: 207.7+/-144.5 mL), operation time (misoprostol group: 113.3+/-28.2 min vs. no agent group: 113.4+/-31.5 min), and hemoglobin change (misoprostol group: 2.0+/-1.0 g/dL vs. no agent group: 1.9+/-1.0 g/dL). Two patients needed transfusion in misoprostol group whereas none in control group, but there was no statistical significance. CONCLUSION: A single preoperative dose of transrectal misoprostol cannot reduce bleeding during laparoscopic myomectomy.

The effectiveness of levonorgestrel releasing intrauterine system in the treatment of endometrial hyperplasia in Korean women / 부인종양

OBJECTIVE: Levonorgestrel releasing intrauterine system (LNG-IUS) has been shown to treat patients with non-atypical & atypical endometrial hyperplasia (EH) successfully in many western studies. Our purpose was to examine the effectiveness of LNG-IUS in the treatment of Korean women with EH. METHODS: We conducted a prospective observational study of 12 women diagnosed with EH and treated with LNG-IUS insertion between February 2007 and August 2009 at the Department of Gynecology of Gangnam CHA Hospital, CHA University School of Medicine. Baseline endometrial biopsies were done before insertion of LNG-IUS, and outpatient follow-up endometrial biopsies were undertaken at 3-month intervals after insertion of LNG-IUS. We investigated the regression rate and the time to regression. RESULTS: Four patients had simple hyperplasia without atypia, 7 patients complex hyperplasia without atypia, and just 1 patient complex atypical hyperplasia. Complete regression of EH was achieved in all cases (100%, 12/12), with the significant proportion (66%, 8/12) achieving it within 3 months. The mean duration to regression was 4.5 months. All cases had regression within 9 months. In the case of complex atypical hyperplasia, the regression was attained at the 9th month after insertion of LNG-IUS. The mean follow-up duration was 12 months (range, 3 to 27 months). As long as LNG-IUS was maintained, the EH did not recur. CONCLUSION: LNG-IUS appears to be as highly effective in treating Korean women with EH.

Cellular fibroma of the ovary containing Leydig cell hyperplasia: a case report / 부인종양

Ovarian stromal tumors containing Leydig cell components are rare. Only a few cases of ovarian stromal Leydig cell tumors characterized by clusters of Leydig cells have been reported to date. Here, we present the first case report of a 65-year-old woman with a cellular fibroma of the ovary containing Leydig cell hyperplasia. Microscopic examination revealed the proliferation of spindle cells arranged in intersecting bundles with mild nuclear atypia and an average of 2-3 mitotic figures per ten high-power fields. Multifocal nests of polygonal cells with abundant eosinophilic cytoplasm and round nuclei were seen within the spindle cells. Final pathology of the tumor revealed a cellular fibroma including Leydig cell hyperplasia.

Clinical Significance of Microsatellite Instability in Sporadic Epithelial Ovarian Tumors

PURPOSE: We evaluated the expression of microsatellite instability (MSI) in sporadic ovarian tumors using 5 standard and 9 new MSI markers to determine the clinical significance of MSI in sporadic epithelial ovarian tumors. MATERIALS AND METHODS: MSI was examined in 21 borderline and 25 malignant ovarian tumors. Polymerase chain reaction (PCR) was performed using the 5 markers recommended by the National Cancer Institute (NCI) for colon cancer and 9 additional markers. MSI was determined using fractional analysis by mixing the PCR products and size markers. RESULTS: Using the 5 conventional MSI markers, MSI was found in 4 of 46 (8.6%) ovarian tumors, including 2 of 21 (9.5%) borderline ovarian tumors and 2 of 25 (8%) malignant ovarian tumors. Using the 9 additional MSI markers, MSI was observed in 7 of 46 (15.2%) ovarian tumors, including 3 of 21 (14.3%) borderline ovarian tumors and 4 of 25 (16%) malignant ovarian tumors. There was no statistically significant difference between MSI and clinicopathological factors, including histology and stage, although there was a trend toward an increased incidence of MSI in the serous type. CONCLUSION: MSI was infrequent in ovarian tumors, including both borderline and malignant tumors. MSI was found to be uncommon in sporadic ovarian tumors, even by using additional MSI markers. The clinical significance of MSI is not strong in patients with sporadic ovarian tumors.

Comparison of surgical outcomes after laparoscopy-assisted vaginal hysterectomy and total laparoscopic hysterectomy / 대한산부인과학회지

OBJECTIVE: To compare the surgical outcomes between laparoscopy-assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH). METHODS: The data were collected retrospectively from hospital records. Between September 2006 and August 2007, Patients undergone with LAVH (93 cases) and TLH (142 cases) with pathologic reports of leiomyoma or adenomyosis were enrolled. The characteristics and surgical results were compared according to the operation type. The correlations among the variables were analyzed with multiple linear regression. RESULTS: Between two groups, the characteristics of patients were similar such as age, body mass index, surgical history, and pathologic findings. In the univariate analysis, the differences of operation duration and blood loss between LAVH (129.0+/-34.5 min, 385.5+/-296.1 mL) and TLH (123.6+/-40.8 min, 294.7+/-285.4 mL) were significant (P0.050). In multivariate analysis, blood loss was correlated with operation duration and specimen weight (P=0.000) but not with operation type (P=0.213). CONCLUSIONS: LAVH tends to be selected in larger uteri and results in more blood loss and longer operation duration. Operation type (LAVH or TLH) does not affect blood loss which is related with operation duration and uterine weight.

The expression and interaction of HLA-G and IL-10 in cervical cancer / 대한산부인과학회지

OBJECTIVES: To determine the expression of HLA-G and IL-10 and their correlation in tissue of cervical cancer, and to investigate the relationship between their expression and clinicopathologic factors in patients with cervical cancer. METHODS: Tissue samples were obtained from 40 patients diagnosed with cervical cancer and 15 patients with normal cervix for control from Oct. 2004 to Oct. 2005. Quantitative real-time RT-PCR for HLA-G mRNA and semi-quantitative RT-PCR for IL-10 mRNA were used. And proteins of HLA-G and IL-10 were detected by Western blot analysis. RESULTS: Both HLA-G and IL-10 mRNA expression in cervical cancer tissue were higher than normal control, which was statistically significant (P<0.001, P<0.001). The proteins levels of HLA-G and IL-10 in cancer group were also significantly higher than control (P<0.001, P=0.041). The mRNA expression of HLA-G tended to be correlated with IL-10 expression (P=0.061), although it was not statistically significant. Among clinicopathologic factors of cervical cancer, there was inverse relationship between FIGO stage and mRNA value of HLA-G (P=0.045). CONCLUSIONS: The mRNA and protein expression of HLA-G and IL-10 in cervical cancer were much higher than in controls. These results showed that HLA-G and IL-10 might have an important role of tumorigenesis in patients with cervical cancer. The levels of HLA-G and IL-10 seem to be correlated although it was not statistically significant. High HLA-G mRNA expression could be related in early tumorigenesis since it was associated with early stage cervical cancer.

An Ovarian Steroid Cell Tumor Causing Virilization and Massive Ascites

Steroid cell tumors, not otherwise specified (NOS), are rare ovarian sex cord-stromal tumors with malignant potential. The majority of these tumors produce several steroids, particularly testosterone. Various virilizing symptoms such as hirsutism, temporal balding, and amenorrhea are common in these patients; however massive ascites is an infrequent symptom. A 52-year-old woman with the sudden onset of virilization and massive ascites presented for treatment at Severance Hospital. After clinical evaluation, the patient underwent an exploratory laparotomy and a complete surgical staging procedure. She recovered from the surgery uneventfully and was discharged from the hospital five days after surgery. We present here an unusual case of an ovarian steroid cell tumor, NOS, and a brief review of the literature regarding these types of tumors.

Tumor volume measured by 3-D magnetic resonance imaging in the prediction of prognosis for cervical carcinoma / 대한산부인과학회지

OBJECTIVE: Clinical evaluation of tumor size in cervical cancer is often difficult. Digital imaging technique using computer has shown an eye opening progress. Quantitative analysis of tumor size or tumor volume using magnetic resonance imaging (MRI) has been reported as useful in the prediction of prognosis in patients with cervical cancer. The purpose of this study was to evaluate whether quantitative analysis can further improve the efficacy of using MR imaging to predict the prognosis of cervical cancer. METHODS: MRI on 0.5- or 1.5-T scanners was performed in 93 consecutive women with invasive carcinoma of the uterine cervix. Initial tumor diameter and volume were determined on T2-weighted images; volume was calculated by the standard technique of multiplying the sum of the areas by the slice thickness. Patients were treated by radical surgery, radiotherapy, or a concurrent chemoradiotherapy based on clinical International Federation of Gynecology and Obstetrics (FIGO) stage and individual patient criteria. Clinical data (patient age and FIGO stage), MRI-derived tumor dimensions (diameter and volume), and histological findings (tumor invasion depth and histological type) were associated and linked to patient outcome. RESULTS: Tumor volume on MRI was significantly associated with recurrence of cervical cancer (P=0.018). Univariate analysis demonstrated graphically that MRI-derived tumor volume and clinical stage were associated with progression-free survival. CONCLUSION: Our preliminary results suggest that tumor volume, determined by pretreatment MRI, predict progression-free survival for patients with invasive cervical carcinoma. This study reveals the value of MRI as an adjunctive tool to clinical evaluation of invasive cervical cancer.

Predicting parameters of survival in patients with vulva carcinoma: its relationship with human papillomavirus infection / 대한산부인과학회지

OBJECTIVES: This study was conducted to evaluate the relationship between HPV infection status and clinicopathologic parameters and to define the predictive parameters including treatment modality affecting survival in patients with vulva cancer. MATERIALS AND METHODS: Data were collected from 30 patients who were diagnosed for vulva carcinoma from Jan 1991 to June 2005. The cancer-related variables including age, stage, cell type, lesion size, multifocality, lymph node involvement, treatment modality and HPV infection were evaluated by reviewing medical records. Statistical analysis was performed by chi-square, log rank test and Cox proportional hazards analysis using SPSS program. RESULTS: Among all 30 patients of vulva carcinoma, HPV infection status was tested in 17 patients. And of these patients, 11 (64.7%) had positive HPV infection. Although there was no survival difference according to HPV infection status, patients with positive HPV infection had significantly more positive lymph nodes (p=0.04). Among all the cancer-related variables, radiation therapy was significantly more associated with poor overall survival than surgery (p=0.007). And squamous cell type was related with decreased overall survival although not statistically significant (p=0.06). However, on the basis of multivariate analysis, there was no significant independent prognostic factor affecting overall survival for vulva carcinoma. CONCLUSIONS: Although this study didn't show any direct relationship between HPV infection and prognosis, HPV infected patients were significantly associated with lymph node metastasis. And the surgery might be an important treatment modality affecting overall survival in patients with vulva carcinoma.

Clinical significance of serum carbohydrate antigen 19-9 in ovarian mature cystic teratoma / 대한산부인과학회지

OBJECTIVE: This study is to determine serum carbohydrate antigen (CA) 19-9 levels in ovarian mature cystic teratoma (MCT) as a possible differential diagnostic tool. METHODS: The study group was composed of 201 patients who underwent removal of ovarian MCT and pathologically confirmed at Yonsei University Medical Center from January 2001 to July 2005. All of them were tested for serum CA19-9 levels before operation. Their data was compared with routine gynecologic evaluation group who showed normal serum CA19-9 level. Statistical analysis was carried out with t-test and Pearson correlation by SPSS version 12.0. RESULTS: Serum CA19-9 level was significantly elevated in the patients with ovarian MCT (p=0.011). Serum CA19-9 level and size of MCT showed positive correlation (p=0.009). Moreover, postoperative serum CA19-9 level showed significant decrease, compared to preoperative level (p=0.007). CONCLUSION: Serum CA19-9 can be used as an effective method for differential diagnosis of ovarian MCT, and it is proper to be used as a postoperative follow-up test.

Paget's disease of the vulva / 대한산부인과학회지

OBJECTIVE: This study of Paget's disease of the vulva was conducted to evaluate whether the initial presenting symptoms, associated diseases and basic screening studies such as imaging studies and tumor markers could be used to predict the state of the disease, and to investigate whether the state of resection margins, bilaterality of the lesion, and the extent of the resection correlated with recurrence. METHODS: This retrospective study was performed on 7 patients diagnosed as Paget's disease of the vulva from March, 1996 to April, 2006. RESULTS: The average age of the patients was 62 year old (range, form 53 to 70). All patients had been menopaused with sustained inflammation signs, eczematoid skin lesion and pain of the external genitalia. None was related to the associated diseases. Preoperative radiologic imaging and tumor marker levels could not determine the extent of diseases. The patients were observed for a period of 31.6 months in average following surgery, during which the disease recurred in one patient. The factors such as resection margin status, bilaterality of the lesion, and the extent of the resection were not valid for indicating the recurrences. CONCLUSION: As we have studied, there is limits to predict the recurrence or the state of the disease. Thus leaving enough resection margins for treatment and long term close follow-up should be essential for treatment of patients with Paget's disease of the vulva.

Primary ovarian hepatoid carcinoma: Case report with review of the literature / 부인종양

Hepatoid carcinoma is histologically similar to hepatocelluar carcinoma and produce alfa-fetoprotein. Ovarian hepatoid carcinoma is extremely rare whether primary or metastatic. We experienced one case of primary ovarian hepatoid carcinoma. In this case report, we present histologic findings, therapeutic modalities of primary hepatoid carcinoma with review of literatures.

Relationship between Flow Cytometric Nuclear DNA Quantification and Clinicopathologic Parameters in Endometrial Cancer / 대한산부인과학회지

OBJECTIVE: The aim of this study was to investigate the relationship of the DNA ploidy, S-phase fraction to other clinicopathologic factors including age, stage, architecture grade, nuclear grade, lymph node involvement, myometrial invasion in patients with endometrial cancer. METHODS: A prospective analysis was performed on 66 endometrial cancer cases treated at our hospital from Jan. 2000 to Nov. 2004. Of these 66 cases, 41 cases were analyzed by flow cytometry. Fresh tissues for analysis were obtained by dilatation and curettage or surgery as hysterectomy. All specimens for histopathologic grading and stage were classified according to WHO criteria and FIGO stage. DNA ploidy groups were divided into two groups, diploidy and aneuploidy. Fraction more than 6% was classified as high percentage S-phase fraction (SPF). DNA ploidy and SPF were analyzed by flow cytometry in fresh surgical specimens from endometrial cancer. RESULTS: Of the 41 cases, 5cases were aneuploidy, and 16 cases were high percentage SPF. With regard to DNA ploidy and clinicopathologic prognostic factors, aneuploidy was significantly increased as stage, histological type, nuclear grade, architecture grade, and myometrial invasion increased. With regard to DNA ploidy and clinical prognostic factors, aneuploidy was not increased as age, lymph node involvement increased. With regard to SPF and clinicopathologic prognostic factors, high percentage SPF (>6%) was significantly increased as stage, histological type, and nuclear grade increased. With regard to SPF and clinicopathologic prognostic factors, high percentage SPF (>6%) was not increased as age, lymph node involvement, architecture grade, and myometrial invasion increased. CONCLUSION: The DNA ploidy by flow cytometry has shown to have a close relationship to stage, histological type, myometrial invasion, and nuclear and architecture grade. Also, the SPF has shown to have a close relationship to stage, histological type, and nuclear grade. Our results were consistent with the concept that aneuploidy or high percentage SPF could predict the poor prognosis of disease course. The flow cytometric DNA quantification in endometrial cancer may provide major information about tumor prognosis.

A case of ovarian fibrosarcoma with pregnancy / 대한산부인과학회지

Ovarian fibromas originating primarily from the ovarian stroma are rare, accounting for approximately 4% of all ovarian neoplasm. The ovarian fibromas are mostly benign tumors, but infrequently they have histologically malignant appearances such as hypercellularity, high mitotic rate, marked nuclear pleomorphism. Malignant fibromatous tumor can be categorized on the basis of prognosis into two separate types of tumors, one of which is cellular fibroma (one to three miotic counts per 10 high power fields) and the other of which is fibrosarcoma (over four miotic counts per 10 high power fields) that has extremely poor prognosis. We report a case of large ovarian fibrosarcoma accompanied with pregnancy and have a brief review of literatures.

Robot-assisted total laparoscopic hysterectomy: initial experience in Korea / 대한산부인과학회지

Hysterectomy is one of the most common non-pregnancy-associated surgical techniques in the field of gynecology. Over the years, this laparoscopic approach has evolved to include both subtotal and total laparoscopic hysterectomy. Robot-assisted technology may attenuate the learning curve for complex laparoscopic procedures, leveling the playing field between conventional laparotomy practitioners and laparoscopists. The advantages of robotics, such as motion scaling, three-dimensional visualization, and articulated instrumentation, enables complex surgical procedures to be performed with greater dexterity, more quickly, and more easily by many surgeons. We have experienced a case of patient with carcinoma in situ of the uterine cervix treated by robotic surgery. We report the first case treated by robotic total laparoscopic hysterectomy with a brief review of literature.

Multimodality therapy in uterine sarcoma / 대한산부인과학회지

Uterine sarcomas have been known for the poor prognosis and high mortality rate. In addition, since uterine sarcomas are a rare group and heterogenous group of tumors with many pathologic subtypes, it is difficult to define optimal management in patients with uterine sarcoma. Total abdominal hysterectomy and bilateral salpingo-oophorectomy have been considered as the cornerstone of treatment for patients with uterine sarcoma, although the efficacy of adnexectomy or lymphadenectomy is still controversial in several subtypes. Also, the role of adjuvant therapy including chemotherapy or radiotherapy remains unclear, although many studies support a possible benefit in terms of progression-free interval or pelvic control. In advanced uterine sarcoma, through the clinical trial, doxorubicin for leimyosarcoma and ifosfamide alone or with combination cisplatin for mixed mesodermal sarcoma represent reasonable therapeutic options. Recently gemcitabine combined with docetaxel has shown promising results for patients with leiomyosarcoma and there are currently some ongoing randomized clinical trials through the Gynecology Oncology Group. In conclusions, multi-institution, randomized clinical trials by histological stratification or accounting to the difference in natural history are more needed actively in patients with uterine sarcoma.