Classification of endometriosis / 영남의대학술지

Endometriosis is a chronic disease associated with pelvic pain and infertility. Several classification systems for the severity of endometriosis have been proposed. Of these, the revised American Society for Reproductive Medicine classification is the most well-known. The ENZIAN classification was developed to classify deep infiltrating endometriosis and focused on the retroperitoneal structures. The endometriosis fertility index was developed to predict the fertility outcomes in patients who underwent surgery for endometriosis. Finally, the American Association of Gynecological Laparoscopists classification is currently being developed, for which 30 endometriosis experts are analyzing and researching data by assigning scores to categories considered important; however, it has not yet been fully validated and published. Currently, none of the classification systems are considered the gold standard. In this article, we review the classification systems, identify their pros and cons, and discuss what improvements need to be made to each system in the future.

Tacrolimus for Treating Orbital and Cranial Form of Idiopathic Inflammatory Pseudotumors

Background@#and Purpose: Orbital and cranial form of idiopathic inflammatory pseudotumors (IIPs) are rare disorders with heterogeneous clinical presentations. Corticosteroids have been the first-line treatment for IIPs, but they are not always effective. @*Methods@#We reviewed the medical records of three patients with orbital or cranial form of IIP who were treated with tacrolimus as an adjuvant treatment. @*Results@#The three patients showed favorable outcomes with the addition of tacrolimus, which is a calcineurin inhibitor that inhibits T-cell activation and T-cell-dependent B-cell activation. @*Conclusions@#Tacrolimus may be a safe and effective immunosuppressant for refractory or relapsing form of orbital or cranial IIPs.

Clinical outcomes of hysterectomy for benign diseases in the female genital tract: 6 years’ experience in a single institute / 영남의대학술지

Background@#Hysterectomy is one of the major gynecologic surgeries. Historically, several surgical procedures have been used for hysterectomy. The present study aims to evaluate the surgical trends and clinical outcomes of hysterectomy performed for benign diseases at the Yeungnam University Hospital. @*Methods@#We retrospectively reviewed patients who underwent a hysterectomy for benign diseases from 2013 to 2018. Data included the patients’ demographic characteristics, surgical indications, hysterectomy procedures, postoperative pathologies, and perioperative outcomes. @*Results@#A total of 809 patients were included. The three major indications for hysterectomy were uterine leiomyoma, pelvic organ prolapse, and adenomyosis. The most common procedure was total laparoscopic hysterectomy (TLH, 45.2%), followed by open hysterectomy (32.6%). During the study period, the rate of open hysterectomy was nearly constant (29.4%–38.1%). The mean operative time was the shortest in the single-port laparoscopic assisted vaginal hysterectomy (LAVH, 89.5 minutes), followed by vaginal hysterectomy (VH, 96.8 minutes) and TLH (105 minutes). The mean decrease in postoperative hemoglobin level was minimum in single-port LAVH (1.8 g/dL) and VH (1.8 g/dL). Conversion to open surgery or multi-port surgery occurred in five cases (0.6%). Surgical complications including wound dehiscence, organ injuries, and conditions requiring reoperation were observed in 52 cases (6.4%). @*Conclusion@#Minimally invasive approach was used for most hysterectomies for benign diseases, but the rate of open hysterectomy has mostly remained constant. Single-port LAVH and VH showed the most tolerable outcomes in terms of operative time and postoperative drop in hemoglobin level in selected cases.

Clinical and histopathologic analysis of gynecological cancer: a single institute experience over 7 years / 영남의대학술지

Background@#Approximately 100,000 women are diagnosed with cancer each year in Korea. According to a survey by the Korean central cancer registry in 2016, uterine cervical cancer, uterine corpus cancer, and ovarian cancer were the 5th, 7th, and 8th most prevalent cancers respectively among Korean women. The present study aims to review the clinico-pathologic characteristics of patients who were treated for major gynecological malignancies at Yeungnam University Medical Center. @*Methods@#Patients with invasive gynecological cancers from January 2012 to February 2019 were retrospectively identified. We analyzed the clinical features, demographic profiles, pathologic data, treatment modality used, adjuvant treatment used, complications, recurrence, and survival outcomes. @*Results@#A total of 287 patients (cervical cancer 115; corporal cancer 86; and ovarian, tubal, or primary peritoneal cancer 90) were included. Most cervical (82.7%) and corporal cancers (89.5%) were diagnosed in the early stages (stage I or II), while more than half (58.9%) the cases of ovarian, tubal or peritoneal cancers were diagnosed in the advanced stages (stage III or IV). Surgical complications were observed in 12.2% of cervical cancers, 16.3% of uterine corpus cancers, and 11.1% of ovarian, tubal, and peritoneal cancers, respectively. The 5-year overall survival rate was 94.1%, 91.0%, and 77.1% for cervical, corporal, and ovarian, tubal, or peritoneal cancers, respectively. @*Conclusion@#Surgical treatment was satisfactory in terms of the incidence of complications, and survival outcomes were generally good. Clinicians should be aware of the clinical and histopathological characteristics of patients with gynecological cancers to be able to provide optimal strategies and counseling.

Multiple Embolic Infarcts Caused by Infective Endocarditis Associated with Atrioesophageal Fistula after Percutaneous Radiofrequency Catheter Ablation for Atrial Fibrillation

Infective endocarditis (IE) is not a common cause of stroke. Considering the high mortality rates, however, IE should always be considered as a possible cause of stroke even when the chances are low. Atrioesophageal fistula is a life-threatening condition that can cause IE and subsequent stroke, but the diagnosis is often delayed due to its rarity. We report a case of multiple embolic infarcts caused by infective endocarditis associated with atrioesophageal fistula after radiofrequency catheter ablation for atrial fibrillation.

Successful delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a twin pregnancy / 영남의대학술지

There has been a significant increase in the number of multiple pregnancies that are associated with a high risk of preterm delivery among Korean women. However, to date, delayed-interval delivery in women with multiple pregnancy is rare. We report a case of delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a dichorionic diamniotic twin pregnancy. The patient presented with vaginal leakage of amniotic fluid at 16 weeks of gestation and was diagnosed with a preterm premature rupture of membranes. Three days later, the first twin was delivered, but the neonate died soon after. The second twin remained in utero, and we decided to retain the fetus in utero to reduce the morbidity and mortality associated with a preterm birth. The patient was managed with antibiotics and tocolytics. Cervical cerclage was not performed. The second twin was delivered vaginally at 34 weeks and 5 days of gestation, 128 days after the delivery of the first-born fetus. This neonate was healthy and showed normal development during the 1-year follow-up period. Based on our experience with this case, we propose that delayed-interval delivery may improve perinatal survival and decrease morbidity in the second neonate in highly selected cases.

Recent advances in minimally invasive surgery for gynecologic indications / 영남의대학술지

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

Puerperal septic shock and necrotizing fasciitis caused by Staphylococcus caprae and Escherichia coli / 영남의대학술지

Puerperal sepsis is one of the leading causes of maternal morbidity and mortality worldwide. Postpartum pelvic infections can cause various complications, including wound infections and necrotizing fasciitis. Several microorganisms are known to cause such infections; however, no study has reported on Staphylococcus caprae, a coagulase-negative staphylococcus that is isolated frequently from animals and infrequently from human specimens, as a causative agent. Here, we report a rare case of septic shock complicated by necrotizing fasciitis after a cesarean section. This is the first report of a human isolate of S. caprae in association with puerperal sepsis and necrotizing fasciitis.

Recent advances in minimally invasive surgery for gynecologic indications / 영남의대학술지

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

Puerperal septic shock and necrotizing fasciitis caused by Staphylococcus caprae and Escherichia coli / 영남의대학술지

Puerperal sepsis is one of the leading causes of maternal morbidity and mortality worldwide. Postpartum pelvic infections can cause various complications, including wound infections and necrotizing fasciitis. Several microorganisms are known to cause such infections; however, no study has reported on Staphylococcus caprae, a coagulase-negative staphylococcus that is isolated frequently from animals and infrequently from human specimens, as a causative agent. Here, we report a rare case of septic shock complicated by necrotizing fasciitis after a cesarean section. This is the first report of a human isolate of S. caprae in association with puerperal sepsis and necrotizing fasciitis.

Successful delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a twin pregnancy / 영남의대학술지

There has been a significant increase in the number of multiple pregnancies that are associated with a high risk of preterm delivery among Korean women. However, to date, delayed-interval delivery in women with multiple pregnancy is rare. We report a case of delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a dichorionic diamniotic twin pregnancy. The patient presented with vaginal leakage of amniotic fluid at 16 weeks of gestation and was diagnosed with a preterm premature rupture of membranes. Three days later, the first twin was delivered, but the neonate died soon after. The second twin remained in utero, and we decided to retain the fetus in utero to reduce the morbidity and mortality associated with a preterm birth. The patient was managed with antibiotics and tocolytics. Cervical cerclage was not performed. The second twin was delivered vaginally at 34 weeks and 5 days of gestation, 128 days after the delivery of the first-born fetus. This neonate was healthy and showed normal development during the 1-year follow-up period. Based on our experience with this case, we propose that delayed-interval delivery may improve perinatal survival and decrease morbidity in the second neonate in highly selected cases.

Histopathological Findings of Intracranial Thrombi in Nonbacterial Thrombotic Endocarditis / 대한뇌졸중학회지

No abstract available.

Hypertension in pregnancy

Hypertension is the most common medical disorder encountered in pregnancy, complicating 5% to 10% of all pregnancies. It is a major cause of maternal, fetal and newborn morbidity and mortality, increasing the risk of cerebrovascular events, organ failure and placenta abruptio in mothers and the risk of intrauterine growth restriction, prematurity and intrauterine death in fetuses. There are four types of hypertensive disorders in pregnancy: gestational hypertension, preeclampsia and eclampsia syndrome, chronic hypertension of any etiology, and Preeclampsia superimposed on chronic hypertension. The decision to treat hypertension in pregnancy should consider the benefit-harm balance for both mother and fetus, and depends on gestational age, blood pressure levels, and presence of preeclampsia. As termination of pregnancy is the only cure for preeclampsia, there is general agreement that delivery rather than observation is suggested in women with severe preeclampsia, eclampsia, or mild hypertension at term. However, it is not clear whether women with mild hypertension at near term can be managed expectantly as well as whether antihypertensive therapy for mild to moderate hypertension should be initiated. In 2013, the American College of Obstetricians and Gynecologists provided evidence-based recommendations for the management of patients with hypertension during and after pregnancy, but it concluded that the final decision should be individualized and made by the health care provider and patient in all instances. Therefore, well-designed large trials are needed to clarify the indication for antihypertensive use and the selected population who would benefit from expectant management for mild to moderate hypertension at preterm.

Survival outcomes and toxicity of intraoperative intraperitoneal chemotherapy in advanced epithelial ovarian cancer

OBJECTIVE: To assess the effect of single-dose cisplatin intraperitoneally administered during cytoreductive surgery in advanced epithelial ovarian cancer. METHODS: Data from patients who underwent surgical management followed by intravenous (IV) chemotherapy for stage III epithelial ovarian cancer from 2003 to 2012 were retrospectively reviewed. Subjects were divided into intraperitoneal (IP) and no-intraperitoneal (NIP) groups according to the administration of IP cisplatin 100 mg during the staging surgery. Clinical results such as survival outcomes and chemotherapeutic toxicity were compared between the two groups. RESULTS: Thirty-seven patients in the IP group and 26 in the NIP group were identified. There were no significant differences between the two groups in basic characteristics such as age, histology, and surgical procedures. After the surgery with or without IP chemotherapy, there was no difference in the rate of either hematologic or gastrointestinal toxicity or in the rate of incompletion of following IV chemotherapy. Tumor recurrence occurred in 67.6% (25 patients) of IP group and 57.7% (15 patients) of NIP group (P=0.423) during the mean follow-up period of 37 months. The 3-year disease free-survival rate was 39.9% in the IP group and 35.8% in the NIP group, and the relative risk of recurrence was 0.864 (95% confidence interval, 0.447-1.673; P=0.665) in the IP group as compared with the NIP group. CONCLUSION: IP chemotherapy with single-dose cisplatin during cytoreductive surgery is safe and feasible with little chemotherapeutic toxicity in advanced epithelial ovarian cancer, but no distinct improvement in survival could be demonstrated in the present study.

Comparison of laparoscopy and laparotomy for the management of early-stage ovarian cancer: surgical and oncological outcomes / 부인종양

OBJECTIVE: To investigate the surgical and oncological outcomes of laparoscopic surgery compared with laparotomy for the treatment of early-stage ovarian cancer. METHODS: Data from patients who underwent surgical management for early-stage ovarian cancer between 2006 and 2012 were retrospectively reviewed. All patients presented with stage I or II disease, and underwent comprehensive staging surgery consisting of a total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy, and peritoneal cytology. RESULTS: Seventy-seven patients who underwent laparoscopic surgery (24 patients) or laparotomy (53 patients) were identified. Surgery for none of the patients was converted from laparoscopy to laparotomy. The mean operation time was shorter and the estimated blood loss was lower in the laparoscopy group than in the laparotomy group, though the differences were not statistically significant (193 min vs. 224 min, p=0.127; 698 mL vs. 973 mL, p=0.127). There were no differences in the intraoperative or postoperative complications. During a mean follow-up period of 31 months, tumor recurrence occurred in 4 patients: 2 (8.3%) in the laparoscopy group and 2 (3.8%) in the laparotomy group. The mean disease-free survival was 59 months after laparoscopy and 66 months after laparotomy (p=0.367). CONCLUSION: Laparoscopic surgery seems to be adequate and feasible for the treatment of early-stage ovarian cancer with comparable results to laparotomy in terms of the surgical outcomes and oncological safety.

Clinical experience in ovarian squamous cell carcinoma arising from mature cystic teratoma: A rare entity

OBJECTIVE: We sought to investigate the clinicopathologic features of ovarian squamous cell carcinomas arising from mature cystic teratomas (MCT) and to report our clinical experience and lessons learned. METHODS: From January 1993 to November 2012, a total of 6,260 women with ovarian MCT were surgically treated at Cheil General Hospital and Women's Healthcare Center. Among them, the cases with malignant transformation to squamous cell carcinoma were included in this analysis. Patient demographic characteristics, surgical findings, and prognosis were evaluated retrospectively. RESULTS: Of the 6,260 ovarian MCT patients, four (0.06%) had ovarian squamous cell carcinoma arising from MCT. The mean patient age was 43 years (range, 35-51 years), and the mean tumor size was 12 cm (range, 9-16 cm), with two patients in the International Federation of Gynecology and Obstetrics stage I and the other two in stage III. Upon preoperative imaging, all cases were expected to be benign ovarian tumors, but the preoperative squamous cell carcinoma antigen level was elevated from 1.5 ng/mL in stage Ia to 11.3 ng/mL in stage IIIc, suggesting malignancy, while the CA-125 level was normal in two of the three patients who received the test. Optimal debulking surgery was performed and adjuvant chemotherapy was used in all patients, but death from the recurrence of disease occurred in one patient, whose overall survival was 10 months. CONCLUSION: Ovarian squamous cell carcinoma arising from MCT is extremely rare, and it is rarely diagnosed preoperatively on imaging workups. Measuring the squamous cell carcinoma antigen level might be a useful diagnostic clue, and it might also be predictive of the tumor stage. An adequate staging surgery should be included in the standard treatment, but multicenter studies are needed to confirm this.

Establishment of a Korea HPV cohort study / 부인종양

We have designed a five-year multicentre prospective cohort study in women who are both human papillomavirus (HPV)-positive with either atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) of cervix. This study aimed to analyze the risk of developing a high-grade squamous intraepithelial lesion (HSIL) from either ASCUS or LSIL in HPV-positive women, so called 'progression' rate, to investigate differences in the progression rates according to HPV type-specific infection, and to evaluate the various factors associated with the persistence or clearance of HPV infection in the Korean population. At present, the study protocol composed of cervical cytology, HPV DNA testing, and questionnaire have been conducted actively since the first participant was enrolled in 2010. This study is the first nationwide Korea HPV cohort study. Our data will provide valuable information about not only the ambiguous cytology results of ASCUS and LSIL but also the effect of the specific HPV type and other various factors on the progression to HSIL. Finally, the results of our study will be helpful and applicable to determine the primary cervical cancer prevention strategies.

Conservative surgical treatment combined with GnRH agonist in symptomatic uterine adenomyosis

To investigate the safety and therapeutic outcomes of conservative surgery combined with GnRH agonist for uterine adenomyosis. Eighteen women with symptomatic uterine adenomyosis were analyzed retrospectively at Cheil General Hospital and Women's Healthcare Center, Seoul, Korea, between March 2008 and November 2009. We used the mean numerical rating scale [MRS] for dysmenorrhea and the Mansfield-Voda-Jorgensen menstrual bleeding scale [MVJ] for menorrhagia before and after the treatment. The mean follow-up period was 9.7 months [6-16 months]. The mean surgical time was 92.5 min, the mean estimated blood loss was 238.9 ml, and the mean hospital stay after operation was 3.4 days. The mean decrease of hemoglobin was 2.0 g/dL After combination of surgery and GnRH agonist, the mean MRS of dysmenorrhea decreased significantly from 8.1 to 1.9 [P < 0.001], and the mean MVJ score also decreased from 4.3 to 3.2 [P < 0.05]. This conservative surgery should be considered as a therapeutic option for women with symptomatic adenomyosis who wish to preserve the uterus

Co-occurrence of an adenoma malignum and an endocervical-type adenocarcinoma of the uterine cervix in a woman with Peutz-Jeghers syndrome / 부인종양

We report a rare co-occurrence of an adenoma malignum and an adenocarcinoma in a 30-year-old woman with Peutz-Jeghers syndrome. The woman was diagnosed with Peutz-Jeghers syndrome based on an endoscopic biopsy after vaginal bleeding. A pelvic examination and an MRI revealed the co-occurrence of a 4x5 cm protruding adenocarcinoma of FIGO stage Ib2 based on a punch biopsy and a 4.5x5.7 cm multilocular cystic mass above the solid cancer. The patient received two courses of neoadjuvant chemotherapy, followed by a laparoscopic radical hysterectomy with pelvic lymph node dissection. Pathologic findings were consistent with adenocarcinoma (40%) and adenoma malignum (60%) confined to the cervix. Three courses of adjuvant chemotherapy were performed and no clinical evidence of recurrence was seen during a 12 month follow-up period. This study will contribute to defining the best diagnosis and treatment for these rare complicating tumors.

High malignant female adnexal tumor of probable wolffian origin (FATWO): A case report / 대한산부인과학회지

Female adnexal tumors of probable Wolffian origin (FATWO) are rare. Although the histological features of the benign tumors are recognized, features of malignancy are not well defined in published work because these tumors are particularly rare. In this study, we report a 52-year-old woman with a High malignant FATWO. The frozen biopsy of the fragile uterine mass, located at the left broad ligament, revealed a malignant FATWO with high mitotic figure (up to 36/10 HPF). The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and paraaortic and pelvic lymph node dissection. Pathologic findings were consistent with malignant FATWO infiltrating to the unilateral salpinx without lymph node metastasis. The patient received three cycles of adjuvant treatment with paclitaxel and carboplatin. There was no clinical evidence of recurrence during the 12 months of follow-up; the patient is currently still being followed-up.