Prognostic Model for Survival and Recurrence in Patients with Early-Stage Cervical Cancer: A Korean Gynecologic Oncology Group Study (KGOG 1028) / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#We aimed to develop and validate individual prognostic models in a large cohort of cervical cancer patients that were primarily treated with radical hysterectomy. @*Materials and Methods@#We analyzed 1,441 patients with early-stage cervical cancer treated between 2000 and 2008 from the Korean Gynecologic Oncology Group multi-institutional cohort: a train cohort (n=788) and a test cohort (n=653). Models predicting the risk for overall survival (OS), disease- free survival (DFS), lymphatic recurrence and hematogenous recurrence were developed using Cox analysis and stepwise backward selection and best-model options. The prognostic performance of each model was assessed in an independent patient cohort. Model-classified risk groups were compared to groups based on traditional risk factors. @*Results@#Independent risk factors for OS, DFS, lymphatic recurrence, and hematogenous recurrence were identified for prediction model development. Different combinations of risk factors were shown for each outcome with best predictive value. In train cohort, area under the curve (AUC) at 2 and 5 years were 0.842/0.836 for recurrence, and 0.939/0.882 for OS. When applied to a test cohort, the model also showed accurate prediction result (AUC at 2 and 5 years were 0.799/0.723 for recurrence, and 0.844/0.806 for OS, respectively). The Kaplan-Meier plot by proposed model-classified risk groups showed more distinctive survival differences between each risk group. @*Conclusion@#We developed prognostic models for OS, DFS, lymphatic and hematogenous recurrence in patients with early-stage cervical cancer. Combining weighted clinicopathologic factors, the proposed model can give more individualized predictions in clinical practice.

An extremely rare elderly case of proximal epithelioid sarcoma of the vulva: case report with a review of literatures

We experienced an extremely rare case of proximal epithelioid sarcoma (PES) of the vulva in a 77-year-old woman. After history taking and physical examination, the patient was tentatively diagnosed as having Bartholin’s cyst in the right labium. Based on histopathological and immunohistochemical (IHC) findings, however, a final diagnosis of PES of the vulva was made. After receiving CyberKnife treatment, the patient survived but with recurrent episodes and poor prognosis. In conclusion, our case indicates that patients with PES of the vulva should be appropriately managed with radiotherapy after a differential diagnosis based on histopathological and IHC findings.

An extremely rare elderly case of proximal epithelioid sarcoma of the vulva: case report with a review of literatures

We experienced an extremely rare case of proximal epithelioid sarcoma (PES) of the vulva in a 77-year-old woman. After history taking and physical examination, the patient was tentatively diagnosed as having Bartholin’s cyst in the right labium. Based on histopathological and immunohistochemical (IHC) findings, however, a final diagnosis of PES of the vulva was made. After receiving CyberKnife treatment, the patient survived but with recurrent episodes and poor prognosis. In conclusion, our case indicates that patients with PES of the vulva should be appropriately managed with radiotherapy after a differential diagnosis based on histopathological and IHC findings.

Prognostic significance of pretreatment lymphocyte percentage and age at diagnosis in patients with locally advanced cervical cancer treated with definite radiotherapy

OBJECTIVE: This study aimed to evaluate the prognostic impact of age at diagnosis, and pretreatment hematologic markers, including lymphocyte percentage and the neutrophil-to-lymphocyte ratio (NLR), in patients with locally advanced cervical cancer (LACC) treated with definitive radiotherapy (RT). METHODS: A total of 392 patients with LACC (stage IIb to IVa) treated with cisplatin-based concurrent chemoradiotherapy or RT alone between 2001 and 2012 were retrospectively enrolled. Clinical data and pretreatment complete blood counts were extracted from electronic medical records of the patients, and analyzed. Treatment outcomes, progression-free survival (PFS), and overall survival (OS) were evaluated. RESULTS: Low lymphocyte percentage and a high NLR were associated with younger age, advanced stage, larger tumor size, lymph nodes metastasis, and treatment failure. The cut-off value for lymphocyte percentage and NLR was determined using a receiver operating characteristic curve. In univariate analysis, low lymphocyte percentage (≤24%) was associated with poor PFS and OS, while high NLR ( > 2.8) was significantly associated only with PFS. In multivariate analysis, both lymphocyte percentage (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.40–0.85; P=0.005) and NLR (HR, 1.55; 95% CI, 1.07–2.25; P=0.022) had independent prognostic value for PFS. Compared to younger patients (age ≤50 years), older patients (age > 60 years) had a lower risk of death. CONCLUSION: Although the lymphocyte percentage did not remain significant in multivariate analysis for OS, it was predictive of PFS and OS. Thus, lymphocyte percentage is a simple hematologic parameter with a significant prognostic value in patients with LACC treated with definitive RT.

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.

Discharge criteria should be validated in patients who undergo ambulatory gynecologic surgery / 부인종양

No abstract available.

Guideline adherence to chemotherapy administration safety standards: a survey on nurses in a single institute / 부인종양

OBJECTIVE: Little is known about the guideline adherence of nurses to chemotherapy administration guidelines. We determined the guideline adherence of nurses to the Chemotherapy Administration Safety Standards and the relationship between demographic characteristics and guideline adherence. METHODS: Survey sheets containing two questions on demographic characteristics and 16 questions on the guideline adherence of nurses regarding chemotherapy administration were distributed to all in-patient departments in our hospital in which chemotherapy was performed. All clinical nurses in the department were recommended to respond. RESULTS: Of 202 nurses, 123 responses were collected (61% response rate). The guideline adherence rate was >70% for 15 of 16 questions, but 55% of respondents indicated that there was no competency monitoring for nurses. Nurses with >7 years of clinical nursing experience felt more competent in performing cardiopulmonary resuscitation (CPR) than nurses with <7 years of clinical nursing experience (p=0.032). CONCLUSION: The guideline adherence rate of nurses with respect to chemotherapy administration was high, with the exception of the absence of a competency monitoring for nurses. A significant number of nurses with <7 years of clinical nursing experience felt incompetent in performing CPR.

The type of metastasis is a prognostic factor in disseminated cervical cancer / 부인종양

OBJECTIVE: The objectives of this study were twofold: to verify whether the type of metastasis (lymphatic vs. hematogenous) is a prognostic factor, and to identify molecular markers associated with survival in patients with disseminated cervical cancer. METHODS: Between April 1997 and May 2008, 30 patients with disseminated cervical cancer who had supraclavicular lymph node (N=13) or hematogenous metastases (N=17) were initially treated at our institute. We reviewed medical records to extract clinicopathologic variables. For 17 patients with available pathological specimens, we evaluated the association of immunohistochemical staining for metalloproteinase (MMP)-2, vascular endothelial growth factor (VEGF)-A, and laminin V gamma (LAMC)-2 with survival and clinicopathologic variables via a log-rank test and Cox regression analysis. RESULTS: Patients who had only lymphatic metastasis (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.4 to 19.5) or completed initial treatment (OR, 3.2; 95% CI, 1.1 to 9.9) showed better survival than patients who did not, but none of the molecular markers were associated with survival. Out of 13 patients with only lymphatic metastasis, three patients who had received volume-directed radiation with concurrent chemotherapy had a long-term survival of over two years. However, patients with hematogenous metastasis showed extremely poor prognosis. CONCLUSION: The type of metastasis and completion of initial treatment were associated with prolonged survival in patients with disseminated cervical cancer, and over 20% of patients with lymphatic metastasis were salvaged with volume-directed radiation with concurrent chemotherapy. None of the molecular markers were associated with survival in patients with disseminated cervical cancer.

Detection of Recurrence by 18F-FDG PET in Patients with Endometrial Cancer Showing No Evidence of Disease

This study assessed the feasibility of F-18-fluorodeoxyglucose positron-emission tomography (18F-FDG PET) in the post-therapy surveillance for patients with endometrial cancer showing no evidence of disease (NED). From April 1997 to June 2007, 127 patients with endometrial cancer showing NED were performed 18F-FDG PET scan. The feasibility of 18F-FDG PET for the early detection of recurrence in patients with endometrial cancer was evaluated retrospectively. Of the 127 patients, 32 patients showed positive lesions on 18F-FDG PET scan. Nineteen (19/127 cases, 15%) of them were confirmed to have a recurrence clinically or histologically. The sensitivity, specificity and positive and negative predictive value of 18F-FDG PET for detecting recurrences in patients with endometrial cancer were 100%, 88%, 59% and 100%, respectively. In conclusion, 18F-FDG PET may be a useful method for the post-therapy surveillance in patients with endometrial cancer.

A case of ovarian metastasis on transposed ovary in patient treated for uterine cervical cancer / 대한산부인과학회지

In case of young women treated with ovarian preservation in cervical cancer surgery, it is regarded pertinent to reduce the risk of early menopause resulting from adjuvant pelvic irradiation through ovarian transposition. On the other hand, lots of authors have raised questions in regard with the ovary being possibly affected by micrometastasis. Studies have reported appropriate indications of ovarian transposition and risk factors of ovarian metastasis to cope with this problem. We conducted ovarian transposition with cervical cancer patient who had no ovarian metastasis risk factors reported in previous literature and experienced such case that metastasis took place only in the ovary without spreading to other organs. This study is to report that case based on brief literature review.

Clinicopathologic characteristics and prognostic factors of primary peritoneal carcinoma / 대한산부인과학회지

OBJECTIVE: The objective of this study was to examine the clinicopathologic characteristics and prognostic factors of primary peritoneal carcinoma (PPC). METHODS: Clinicopathologic variables were obtained by examining the medical records of patients with PPC who were diagnosed and treated at our institute, between January 1996 and December 2005. To find prognostic factors, the association of clinicopathologic variables with survival was evaluated by univariate and multivariate analysis. RESULTS: All patients had advanced-stage tumors. Residual tumor was smaller than 1 cm in 12 patients and was equal or larger than 1 cm in nine patients. The response rate to adjuvant chemotherapy was 47.6%. The median progression-free survival was eight months (range 1~95) and the median overall survival was 14 months (range 1~99). In univariate analysis, stage, the response to adjuvant chemotherapy, and neoadjuvant chemotherapy were associated with survival. However, in multivariate analysis, no variables were associated with survival. CONCLUSION: In spite of aggressive treatments, patients with PPC had poor prognosis. No prognostic factors were identified in this study.

Accelerated Hyperfractionated Radiotherapy for Locally Advanced Uterine Cervix Cancers / 대한방사선종양학회지

PURPOSE: To assess the efficacy of the use of accelerated hyperfractionated radiotherapy (AHRT) for locally advanced uterine cervix cancers. MATERIALS AND METHODS: Between May 2000 and September 2002, 179 patients were identified with FIGO stage IIB, IIIB, and IVA cancers. Of the 179 patients, 45 patients were treated with AHRT (AHRT group) and 134 patients were treated with conventional radiotherapy (CRT group), respectively. Patients undergoing the AHRT regimen received a dose of 30 Gy in 20 fractions (1.5 Gyx2 fractions/day) to the whole pelvis. Subsequently, with a midline block, we administered a parametrial boost with a dose of 20 Gy using 2 Gy fractions. Patients also received two courses of low-dose-rate brachytherapy, up to a total dose of 85~90 Gy to point A. In the CRT group of patients, the total dose to point A was 85~90 Gy. The overall treatment duration was a median of 37 and 66 days for patients that received AHRT and CRT, respectively. Statistical analysis was calculated by use of the Kaplan-Meier method, the log-rank test, and Chi-squared test. RESULTS: For patients that received cisplatin-based concurrent chemotherapy and radiotherapy, the local control rate at 5 years was 100% and 79.2% for the AHRT and CRT group of patients, respectively (p=0.028). The 5-year survival rate for patients with a stage IIB bulky tumor was 82.6% and 62.1% for the AHRT group and CRT group, respectively (p=0.040). There was no statistically significant difference for severe late toxicity between the two groups (p=0.561). CONCLUSION: In this study, we observed that treatment with AHRT with concurrent chemotherapy allows a significant advantage of local control and survival for locally advanced uterine cervix cancers.

Validation of a nomogram for predicting outcome of vulvar cancer patients, primarily treated by surgery, in Korean population: multicenter retrospective study through Korean Gynecologic Oncology Group (KGOG-1010) / 부인종양

OBJECTIVE: Regarding vulvar cancer, a nomogram has been suggested for the prediction of relapse-free survival (RFS). While the nomogram has been developed and validated in a Western study, there was no validation in Korean population. Thus, we have undertaken the study to assess the applicability of nomogram for predicting RFS in Korean patients with vulvar cancer. METHODS: A total of 204 cases newly diagnosed as vulvar cancer between 1982 and 2006 were identified. Among them 70 cases were not eligible due to inappropriate cell type (40 cases) and radiation as primary therapy (30 cases). Forty-four cases were not evaluable due to inadequate data and persistent disease. Finally a total of 90 patients primarily treated by surgery were included for analysis. Variables including age and the characteristics of primary tumor, nodal status, and surgical margin were collected for predicting RFS based on nomogram, which was compared with actual RFS. A calibration plot was drawn showing the actual versus predicted probability for 6 groups of patients segregated according to their predicted probabilities. In addition, discrimination of the nomogram was quantified with the concordance index. RESULTS: Patients' mean age was 58 years and mean follow-up period was 47.9 months. Observed 2y- and 5y-RFS rates were 81% and 68%, respectively, corresponding to 79% and 72% in the original cohort. The trend line in calibration plot showed comparable concordance with an ideal line, having a slope of 1.04 for 2y-RFS (R(2)=.35) and 0.98 for 5y-RFS (R2=.80), respectively. The concordance index was 0.79 in the KGOG data set, which was improved to 0.82 with the data set limited to squamous cell carcinoma. CONCLUSION: The nomogram provides the predictive capacity for relapse-free survival in Korean patients with vulvar cancer.

Modalities for evaluation of tumor size in cervical cancer / 부인종양

No abstract available.

A case of primary malignant lymphoma of uterine cervix / 부인종양

Although in the past two decades there has been a sharp rise in the incidence of extranodal primary lymphomas, non-Hodgkin's lymphoma (NHL) of the female genital tract is still rare. There is still no consensus on the management of cervical lymphomas. The malignant lymphoma localized in uterine cervix is rare and characteristically symptom free expressed. A 26-year-old woman presented in March 2004 with uterine bleeding. After the patient underwent punch biopsy, primary cervical malignant lymphoma was diagnosed. Six courses of chemotherapy were administered in an adjuvant setting. Thirty-nine months (May 2007) after the diagnosis the patient was alive and without signs of recurrent disease. In this report, one case of primary cervical lymphoma diagnosed by punch biopsy is reported and associated literature is discussed.

Current status of application of the secondary cytoreductive surgery for patients with epithelial ovarian carcinomas / 대한산부인과학회지

Recurrent ovarian cancer has been considered as a difficult disease to treat despite the rapid development of various chemotherapeutic agents and surgical techniques for several decades. Many investigators tried to establish the optimal triage for treat recurrent or persistent disease applying not only salvage regimen but also debulking surgery. We reviewed many literature concerning the surgical approaches for patients with primary treatment failure to outline the treatment scheme. Most of authors agrees that optimal or even maximal cytoreduction enables survival benefit of patients with refractory disease while the biologic characteristics of tumor may not affect the prognosis.

A case of multiple primary malignancy involving the endometrial cancer / 부인종양

The incidence of multiple primary malignancy is extremely rare although the prevalence rate is increasing recently. There are several reasons of increment of multiple primary malignancy. First, the advances in the treatment and the diagnostic modality of malignancy have led to increased survival rate. So many of the patients who survived the first cancer could live long enough to develop additional primary cancers. Second, the long term effects of chemotherapy and radiation therapy have been proved oncogenic. Third, increasing age, environmental carcinogen, some kinds of viral infection, and genetic predisposition have potentials for multiple carcinogenesis. Most of multiple primary cancer is double primary, however triple primary cancer is rare. We experienced a case of triple primary cancer involving endometrium, colon, and stomach. We report this case with a review of literatures.

The Role of F-18 Fluorodeoxyglucose Positron Emission Tomography in Patients with Malignant Mixed Mullerian Tumors of the Uterus / 핵의학분자영상

PURPOSE: Malignant Mixed Mullerian Tumor (MMMT) of the uterine corpus is one of the very uncommon and the most lethal tumors in the uterus. The aim of this study was to evaluate the role of FDG PET in detecting distant metastasis and residual and/or recurrent disease. METHODS: Ten patients who underwent FDG PET for detecting distant metastasis and recurrence were included. Focal FDG accumulation was regarded as abnormal. We also reviewed serum CA 125 levels, anatomical images, and histopathological examination. RESULTS: Three patients of 10 FDG PET showed abnormal FDG uptake. One had high serum CA 125 levels and high fractions of carcinomatous element on histopathologic examination. FDG PET showed metastatic lesions in unexpected locations, which could not be detected by anatomical images. Another had normal serum CA 125 levels with high sarcomatous element and CT could only detect a few lesions. The other had high serum CA 125 levels and also had high carcinomatous element. Seven patients who had no abnormal uptake on FDG PET had no clinical evidence of recurrence during the follow up period (51.7+/-12.2 months). The mean disease free intervals of these 7 patients were 36.4+/-6.0 months. Two patients with abnormal findings had never become disease-free condition during the follow up period (6.0+/-4.2 months. CONCLUSION: FDG PET could be a useful modality for unexpected distant metastasis and follow up tool in patients with MMMT.

Outcome of cervical cancer in extremely elderly patients receiving radiation therapy / 부인종양

OBJECTIVE: The aim of this study was to evaluate the tolerance and outcome of elderly cervical cancer patients who were treated with radiation therapy retrospectively. METHODS: Fourteen patients over 80 years with pathologically proven stage I-IV cervical cancer who were treated with definitive RT between 1993 and 2003 were analyzed. We investigated response rates, recurrence rates, complications, progression free intervals, and current status of subjects. RESULTS: The age of the 14 patients ranged from 80 to 88 (median age: 81). The distribution of clinical stage by FIGO classification were > or =stage IIB (78.6%). The most common histologic type was squamous cell carcinoma. Nine patients (64.3%) underwent definitive radiation therapy. Among the 9 patients who had undergone radiotherapy, 7 patients (77.8%) showed complete response. One patient underwent surgical intervention followed by chemotherapy due to progression of disease despite radiotherapy. Two patients experienced radiation cystitis and 1 patient suffered from radiation colitis, however, other patients did not manifestate significant complications. One patient who underwent palliative chemotherapy due to persistent disease experienced mild marrow suppression and neurologic symptoms temporarily. CONCLUSION: The elderly patients over 80 years with good performance status may tolerate definitive pelvic radiation administered according to conventional fractionation schedules to control cervical cancer. Definitive radiation therapy with or without concurrent chemotherapy should not be excluded as a treatment option even for patients older than 80 years.

A case of primary leiomyosarcoma of the mesentery with hepatic metastasis / 부인종양

Primary tumors of the mesentery are uncommon, and primary leiomyosarcoma of the mesentery is especially rare, and thus an accurate preoperative diagnosis is difficult. We experienced a case of 32-year female with primary leiomyosarcoma of the mesentery. We report this case with a brief review of the literature.