Comparison of volume-controlled, pressure-controlled, and pressure-controlled volume-guaranteed ventilation during robot-assisted laparoscopic gynecologic surgery in the Trendelenburg position.

Background: Pressure-controlled ventilation volume-guaranteed (PCV-VG) is being increasingly used for ventilation during general anesthesia. Carbon dioxide (CO2) pneumoperitoneum in the Trendelenburg position is routinely used during robot-assisted laparoscopic gynecologic surgery. Here, we hypothesized that PCV-VG would reduce peak inspiratory pressure (Ppeak), compared to volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV). Methods: In total, 60 patients were enrolled in this study and randomly assigned to receive VCV, PCV, or PCV-VG. Hemodynamic variables, respiratory variables, and arterial blood gases were measured in the supine position 15 minutes after the induction of anesthesia (T0), 30 and 60 minutes after CO2 pneumoperitoneum and Trendelenburg positioning (T1 and T2, respectively), and 15 minutes after placement in the supine position at the end of anesthesia (T3). Results: The Ppeak was higher in the VCV group than in the PCV and PCV-VG groups (p=0.011). Mean inspiratory pressure (Pmean) was higher in the PCV and PCV-VG groups than in the VCV group (p<0.001). Dynamic lung compliance (Cdyn) was lower in the VCV group than in the PCV and PCV-VG groups (p=0.001). Conclusion: Compared to VCV, PCV and PCV-VG provided lower Ppeak, higher Pmean, and improved Cdyn, without significant differences in hemodynamic variables or arterial blood gas results during robot-assisted laparoscopic gynecologic surgery with Trendelenburg position.

Association between hysterectomy and depression: a longitudinal follow-up study using a national sample cohort.

OBJECTIVES: This study investigated the influence of hysterectomy on depression using a national sample cohort from South Korea. METHODS: We extracted data entered into the Korean Health Insurance data based form 2002 through 2013 and classified patients into a group of women who had undergone a hysterectomy (n = 9,971) and a 1:4 matched control group (n = 39,884). A Cox proportional hazards model was used to analyze the hazard ratios (HRs) and 95% confidence intervals (CIs) to assess the risk of depression in the hysterectomy group and the control group. The HR was calculated as the risk of depression in the hysterectomy group compared to that in the control group. RESULTS: The incidence of depression in the hysterectomy group was 6.59 per 1,000 person-years and that in the control group was 5.70 per 1,000 person-years. The adjusted HR for depression was 1.15 in the hysterectomy group (95% CI = 1.03-1.29, P < 0.05). In a subgroup analysis, the adjusted HR for depression was 1.16 (95% CI; 1.03-1.31, P = 0.014) for patients who underwent hysterectomy without bilateral salpingo-oophorectomy. In an additional subgroup analysis, the adjusted HR for depression after hysterectomy was 1.18 (95% CI; 1.04-1.35, P = 0.012) in the younger than 50-year-old group. CONCLUSION: The incidence of depression was higher in women who underwent hysterectomy than in the matched control group.

Increased risk of osteoporosis in patients with peptic ulcer: a follow-up study using a national sample cohort.

We performed a nationwide, population-based cohort study to investigate the risk of osteoporosis in patients with peptic ulcer disease in South Korea and concluded that peptic ulcer disease is associated with an increased risk of osteoporosis. PURPOSE: This study aimed to evaluate the association between peptic ulcer disease (PUD) and the occurrence of osteoporosis using a national sample cohort from South Korea. METHODS: Using the national cohort study from the Korean National Health Insurance Service, we extracted data for patients with PUD (n = 50,002) and for 1:1 matched control participants (n = 50,002); we then analyzed the occurrence of osteoporosis from 2002 to 2013. The patients were matched according to age, sex, income, region of residence, and past medical history. A stratified Cox proportional hazards model was used to analyze the hazard ratios (HRs) and the 95% confidence intervals (CIs). Subgroup analyses were performed based on age and sex. RESULTS: The adjusted HR for osteoporosis was 1.36 (95% CI = 1.33-1.40, P < 0.001) in the PUD group. In the subgroup analysis based on age and sex, the respective adjusted HRs of PUD for osteoporosis were 1.33 (95% CI = 1.21-1.47) in the < 65-year-old group of men and 1.42 (95% CI = 1.30-1.56) in the ≥ 65-year-old group of men (each P < 0.001). The respective adjusted HRs of PUD for osteoporosis were 1.34 (95% CI = 1.29-1.39) in the < 65-year-old group of women and 1.38 (95% CI = 1.33-1.47) in the ≥ 65-year-old group of women (each P < 0.001). CONCLUSION: In the current nationwide cohort study, we found that PUD is associated with an increased risk of osteoporosis regardless of sex.

Preoperative Predictive Factors for Complete Cytoreduction and Survival Outcome in Epithelial Ovarian, Tubal, and Peritoneal Cancer After Neoadjuvant Chemotherapy.

OBJECTIVE: The study aims to identify preoperative predictors of complete cytoreduction and early recurrence and death in epithelial ovarian, tubal, and peritoneal cancer after neoadjuvant chemotherapy (NACT). METHODS: We performed a retrospective analysis of 85 patients who underwent 3 cycles of NACT. Patients were divided into 2 groups according to residual tumor at interval debulking surgery (IDS), and clinicopathologic, surgical, and follow-up data were compared. RESULTS: Cancer antigen 125 (CA-125) levels before the IDS after completion of NACT were higher in the residual tumor group (42.0 vs 116.6 U/mL, P = 0.006). The drop rate of CA-125 after NACT was higher in the no residual tumor group (96.8% vs 89.9%, P = 0.001). Patients with residual tumor showed lower disease-free and overall survival outcomes than patients with no residual tumor. In univariate analysis, CA-125 of 100 U/mL or less before IDS and a drop rate after NACT greater than 80% were preoperative predictive factors for complete cytoreduction. In multivariate analysis, a drop rate of CA-125 after NACT greater than 80% was an independent preoperative predictive factor for complete cytoreduction (P = 0.002). Progressive disease on follow-up image during NACT was an independent preoperative predictive factor for early recurrence and death (P < 0.001, both). CONCLUSIONS: A significant drop of CA-125 after NACT and progressive disease on follow-up image are independent preoperative predictors for complete cytoreduction and early recurrence and death.

Investigation of New Therapeutic Targets in Undifferentiated Endometrial Sarcoma.

BACKGROUND: Undifferentiated endometrial sarcoma (UES) is a very rare subtype of uterine sarcoma, which has no consensus on the treatment. We investigated the expression of potential new therapeutic targets in UES to improve its aggressive clinical course and poor survival outcome. METHODS: The immunohistochemical expressions of vascular endothelial growth factor (VEGF), c-KIT, c-ABL, platelet derived growth factor receptor (PDGFR), protein kinase B (AKT1), mammalian target of rapamycin, epidermal growth factor receptor (EGFR), human epidermal growth factor receptor (HER2), Wilms tumor (WT1), aromatase inhibitor (CYP19A1), and histone deacetylase (HDAC) series in 10 UES patients were assessed using tissue microarrays. RESULTS: Strongly positive immunoreactivities were observed for VEGF, AKT1, and HDAC2/7 in 8 (80.0%) tumors; for CYP19A1 and HDAC6 in 9 (90%) tumors; and for HDAC1/4/8 in 10 (100%) tumors. Strong expression of CYP19A1 and HDAC6 was associated with distant recurrence (p = 0.030, both), and expression of WT1 indicated a more advanced stage (p = 0.033). UES treated with adjuvant therapy showed better disease-free and overall survivals (both 0 vs. 33.3%, p = 0.003). CONCLUSION: VEGF, AKT1, CYP19A1, and the HDAC1/2/4/6/7/8 series show an especially high frequency of strong immunoreactivity in UES and can be considered potential therapeutic targets.

Clinical characteristics of genital chlamydia infection in pelvic inflammatory disease.

BACKGROUND: Chlamydia infection in acute pelvic inflammatory disease (PID) is associated with serious complications including ectopic pregnancy, tubal infertility, Fitz-Hugh-Curtis syndrome and tubo-ovarian abscess (TOA). This study compared clinical and laboratory data between PID with and without chlamydia infection. METHODS: The medical records of 497 women who were admitted with PID between 2002 and 2011 were reviewed. The patients were divided into two groups (PID with and without chlamydia infection), which were compared in terms of the patients' characteristics, clinical presentation, and laboratory findings, including inflammatory markers. RESULTS: The chlamydia and non-chlamydia groups comprised 175 and 322 women, respectively. The patients in the chlamydia group were younger and had a higher rate of TOA, a longer mean hospital stay, and had undergone more surgeries than the patients in the non- chlamydia group. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and CA-125 level were higher in the chlamydia group than in the non-chlamydia group, but there was no significant difference in the white blood cell count between the two groups. The CA-125 level was the strongest predictor of chlamydia infection, followed by the ESR and CRP level. The area under the receiving operating curve for CA-125, ESR, and CRP was 0.804, 0.755, and 0.663, respectively. CONCLUSIONS: Chlamydia infection in acute PID is associated with increased level of inflammatory markers, such as CA-125, ESR and CRP, incidence of TOA, operation risk, and longer hospitalization.

Incorporating a 3-dimensional printer into the management of early-stage cervical cancer.

We used a 3-dimensional (3D) printer to create anatomical replicas of real lesions and tested its application in cervical cancer. Our study patient decided to undergo radical hysterectomy after seeing her 3D model which was then used to plan and simulate this surgery. Using 3D printers to create patient-specific 3D tumor models may aid cervical cancer patients make treatment decisions. This technology will lead to better surgical and oncological outcomes for cervical cancer patients. J. Surg. Oncol. 2016;114:150-152. © 2016 Wiley Periodicals, Inc.

Immunohistochemical Characterization of Histone Deacetylase as a Potential Prognostic Marker and Therapeutic Target in Endometrial Stromal Sarcoma.

AIM: Endometrial stromal sarcoma (ESS) is a rare tumor with limited treatment options. Histone deacetylase (HDAC) is a potential therapeutic target in ESS showing a good rate of response in laboratory studies. In this study we investigated the expression of HDAC enzymes in 41 ESS patients. MATERIALS AND METHODS: Immunohistochemical expression of HDACs was analyzed by tissue microarrays. RESULTS: Strong positive immunoreactivity was observed in 32 (78.0%), 23 (56.1%), 8 (19.5%), 36 (87.8%), 7 (17.1%), 30 (73.2%), 31 (75.6%), and 33 (80.5%) for HDACs 1-8, respectively. Although not statistically significant, HDAC 1, 4, 6, 7, and 8 exhibited a high frequency of strong immunoreactivity linked to a lower 10-year DFS (100.0% vs. 81.3%, p=0.202; 100.0% vs. 83.3%, p=0.393; 90.9% vs. 83.3%, p=0.579; 90.0% vs. 83.9%; and 100.0% vs. 81.8%, p=0.207; respectively). CONCLUSION: HDACs 1, 4, 6, 7, and 8, that showed an especially high frequency of strong immunoreactivity, may represent potential therapeutic targets for ESS.

Single-port laparoscopic debulking surgery of variant benign metastatic leiomyomatosis with simultaneous lymphatic spreading and intraperitoneal seeding.

Benign metastatic leiomyomatosis (BML) is a rare disease characterized by smooth muscle cell proliferation in extrauterine sites including the lung, abdomen, pelvis, and retroperitoneum. Depending on location, BML is classified as intravenous leiomyomatosis and diffuse peritoneal leiomyomatosis. Pathogenesis of BML can be iatrogenic after previous myomectomy or hysterectomy, hormonal, or coelomic metaplasia. Treatment options are observation, hormonal suppression, and/or surgical debulking via laparotomy or laparoscopy. Laparoscopic surgery is gaining in popularity in the gynecologic field compared to laparotomic surgery and single-port laparoscopy has the benefits of cosmesis and early tissue extraction by transumbilical morcellation. We report a 39-year-old woman with BML who underwent single-port laparoscopy debulking surgery.

Predictive Markers of Tubo-Ovarian Abscess in Pelvic Inflammatory Disease.

BACKGROUND/AIMS: The purpose of this study was to identify predictive markers for tubo-ovarian abscess (TOA) through a comparison of clinical and laboratory data in patients diagnosed with pelvic inflammatory disease (PID). METHODS: We reviewed the medical charts of 499 females who were admitted to hospital with clinical, surgical, imaging-based diagnoses of PID between 2001 and 2011. The patients were divided into the following two groups: (1) PID with TOA and (2) PID without TOA. RESULTS: The TOA and non-TOA groups were comprised of 69 and 430 females, respectively. Mean age, history of intrauterine device (IUD) insertion and inflammatory markers, including erythrocyte sedimentation rate, C-reactive protein (CRP) and CA-125 levels, were higher in the TOA group than the non-TOA group. Independent factors that predicted TOA were older age, IUD insertion, increased CRP and CA-125, and chlamydia infection. CA-125 was found to have the highest predictive value for TOA. TOA size was associated with increased surgical therapy compared to patients with smaller abscesses. CONCLUSIONS: Increased age, IUD insertion, chlamydia infection, and increased CRP and CA-125 level were the independent factors predictive of TOA in acute PID. These predictive values will be expected to help decrease gynecological morbidity by early diagnosis and appropriate treatment of TOA. © 2015 S. Karger AG, Basel.

Follicular stimulating hormone enhances Notch 1 expression in SK-OV-3 ovarian cancer cells.

OBJECTIVE: Notch is known as a transmembranous receptor family with four homologous forms - Notch 1, Notch 2, Notch 3, and Notch 4 and related to cell fate regulation and angiogenesis. The purpose is to investigate the effect of follicular stimulating hormone (FSH) on the Notch 1 expression and proliferation in ovarian cancer cells. METHODS: Human ovarian cancer cell line, SK-OV-3 and FSH were used. XTT cell proliferation and cell migration assay were carried out with FSH 100 mIU/mL and Notch 1 siRNA. Western blots and reverse transcriptase-polymerase chain reactions (RT-PCR) were carried out to determine the expression level of the Notch 1 protein and mRNA with FSH treatment in 0, 1, 5, 10, 100, 200, 300 mIU/mL concentrations. Immunofluorescent (IF) stains were performed in SK-OV-3 cell cultures with FSH 100 mIU/mL. Student-t tests were used in statistical analyses. RESULTS: The SK-OV-3 have Notch 1 receptors in their natural status. FSH stimulated SK-OV-3 cells in XTT cell proliferation and cell migration assays and notch 1 siRNA inhibited. The expression level of Notch 1 protein and mRNA were increased in a dose dependent pattern according to FSH concentrations compared to untreated cells. IF stains also showed brighter Notch1 expressions in the FSH treated cells compared to the control cells. CONCLUSION: FSH enhances proliferation & migration and Notch 1 signaling in SK-OV-3 cells. The Notch signaling probably supports one of the cell proliferating mechanisms of FSH in ovarian cancer cells.

A case of lymphangioleiomyomatosis originated in the pelvic cavity.

Lymphangioleiomyomatosis is a rare disease that is characterized by proliferation of abnormal smooth muscle-like cells, especially that which occurs in the pulmonary parenchyme. It primarily affects women of child-bearing age. The majority of primary lymphangioleiomyomatosis occurs in the lung, but there are a few reports of extrapulmonary cases. We experienced a rare case of lymphangioleiomyomatosis which originated in the pelvic cavity (in the posterior portion of the uterus), and report with brief review of literatures.

HPV status in sentinel nodes might be a prognostic factor in cervical cancer.

OBJECTIVE: Although there have been studies that focused on the correlation between the HPV presence of pelvic lymph nodes and pathological metastasis in patients with cervical cancer, the biologic role of HPV DNA in lymph nodes still remains uncertain. We performed this study to investigate the correlation between the sentinel-node HPV status and pelvic lymph node metastasis in patients with cervical cancer. The patients were followed up for 3 years to evaluate the clinical role of HPV in sentinel nodes as a prognostic factor. METHODS: From August 2001 to July 2003, 57 patients affected by stages IB-IIA cervical cancer had sentinel-node biopsies performed during radical hysterectomy and pelvic and paraaortic lymphadenectomy. Each detected sentinel node was divided into two parts. One part of them was submitted for frozen section examination and the other was submitted for HPV typing by oligonucleotide microarray. After follow-up, we analyzed the outcome of the patients with respect to the influence of sentinel-node HPV. RESULTS: Sentinel nodes were identified in all patients. A total of 79 nodes from 57 patients were detected as sentinel nodes. Metastasis in the sentinel nodes were found in 10 patients (17.6%) by frozen section and 11 patients by pathologic examination. The results of sentinel lymph node frozen biopsy were statistically significant for predicting the metastasis of the pelvic lymph nodes (P<0.05), but showed one false-negative case. HPV DNA was detected in the cervical cancer lesions of 55 patients (96.5%) and 80.0% (44/55) of them were found to have HPV DNA in the sentinel nodes as well. HPV DNA was detected in sentinel nodes of 10 patients among 11 patients with lymph node metastasis. Disease recurred in five patients and one of them did not show pelvic lymph node metastasis at surgery. But, all of these patients had HPV in sentinel nodes. The combination of sentinel-node frozen biopsy and HPV typing showed a negative predictive value of 100% in predicting non-metastasis of lymph node and no recurrence of disease. CONCLUSION: Our results suggested the possibility that sentinel-node HPV typing could play a supportive role to reduce the false-negative rate of the sentinel-node biopsy. All of five patients with recurrence had HPV infection in the sentinel nodes. Absence of HPV in sentinel nodes showed reliable negative predictive value for lymph node metastasis and recurrence. Additional study will be needed to confirm the clinical application of the sentinel-node procedure and to determine whether there is a correlation of HPV status of sentinel nodes to lymph node metastasis and recurrence in cervical cancer patients.

Usefulness of lymphoscintigraphy and intraoperative gamma probe detection in the identification of sentinel nodes in cervical cancer.

The aim of our study was to prospectively assess the clinical usefulness of sentinel lymphoscintigraphy and intraoperative gamma probe detection in identifying sentinel nodes (SNs) in patients with early cervical carcinoma. Between 6 and 24 h before radical hysterectomy, lymphoscintigrams were obtained following peritumoural injection of technetium-99m antimony sulphur colloid in 26 patients (mean age 45 years, range 32-71 years) with cervical cancer (FIGO I-IIa). Scanning for radioactive nodes was performed using a hand-held collimated gamma-detecting probe in the initial stages of the main operation, during and before exposure of the retroperitoneal spaces. After separation and removal of radioactive, blue nodes, specimens were submitted for pathological evaluation. SNs were successfully localised using a combination of lymphoscintigraphy and intraoperative gamma probe detection in all 26 cases. However, in two of the 26 cases, SNs were only localisable using the gamma-detecting probe. A histologically positive SN was found in only one case. It is concluded that, in cervical cancer, lymphoscintigraphy and SN biopsy using a gamma-detecting probe are easy and reliable methods for the detection of SNs and are of value in defining the necessity and extent of node dissection.

Sentinel node biopsy as an indicator for pelvic nodes dissection in early stage cervical cancer.

The purpose of this study was to investigate the feasibility of sentinel node frozen biopsy to minimize the extensive pelvic lymph nodes dissection in early stage cervical cancer patients on the basis that the risk of skip metastasis to the paraaortic area is negligible. Twenty-six patients with early stage cervical cancer were enrolled in this study. Technetium-99m colloid albumin (Tc(99m)) was injected intradermally around the tumor for allowing preoperative lymphoscintigraphy and intraoperative hand-held gama probe detection of seninel nodes. For visual detection, isosulfan blue dye was injected into the peritumoral sites before peritoneal opening. Postoperative morbidity and negative predictive value were the endpoints of this study. The 26 patients, ranging in age from 32 to 71 yr, underwent intraoperative sentinel nodes mapping. All the patients underwent complete pelvic lymph nodes dissection including para-aortic nodes. There was one case with positive non-sentinel nodes despite the negative sentinel node by frozen biopsy (negative predictive value, 95.2%). This new technique of sentinel node mapping is safe and simple to perform. Further clinical trials using the combination of Tc(99m) and isosulfan blue dye are warranted and this technique will make a true advance for less aggressive management of patients with early stage cervical cancer.