Efficacy of fibrin sealant in reducing hemorrhage after a loop electrosurgical excision procedure.

BACKGROUND/AIMS: We examined the association of fibrin sealant use with post-operative hemorrhage in patients who underwent a loop electrosurgical excision procedure (LEEP). METHODS: We retrospectively collected clinicopathologic data of 344 patients who underwent LEEP at our institute between 2007 and 2009. We defined hemorrhage which occurred between 1 and 30 days after LEEP and required electrocautery to achieve hemostasis as severe secondary hemorrhage (SSH). We determined whether or not the use of fibrin sealant during LEEP was associated with a decreased occurrence of SSH. In addition, we examined the associations of other clinicopathologic variables with SSH and fibrin sealant use. RESULTS: SSH occurred in 6 of 200 patients (3%) with fibrin sealant and in 12 of 144 patients (8%) without fibrin sealant. Based on univariate analysis, the use of fibrin sealant was associated with SSH (p = 0.028). However, age, surgeons and pathologic diagnosis were not associated with SSH. Based on multivariate analysis, the use of fibrin sealant was associated with less SSH (p = 0.033, OR = 0.328, 95% CI 0.117-0.917). CONCLUSION: Fibrin sealant use reduces the incidence of severe post-operative hemorrhage after LEEP.

Clinicopathologic factors for central recurrence in patients with locally advanced bulky cervical cancer.

OBJECTIVE: Locally advanced bulky cervical cancer (LABCC) is characterized by poor local control. The objective of this study was to identify the clinicopathologic variables associated with one-year central-only recurrence, which will serve as criteria for adjuvant hysterectomy after radiation (AHR) in patients with LABCC. STUDY DESIGN: Between January 2000 and August 2007, we retrospectively evaluated outcomes in 225 patients with LABCC who were initially treated with radiation or chemoradiation. RESULTS: Among the 225 patients with LABCC, there were 41 recurrences within one year after treatment (8 central-only and 33 pelvis and/or distant site recurrences). Age, stage, and treatment type were not associated with the one-year central-only recurrences, but tumor size ≥8cm had a statistically significant association based on multivariate analysis (OR, 5.39; 95% CI, 1.15-25.31; p=0.03). The combination of non-squamous cell (non-SCC) type and tumor size ≥8cm had a significantly higher rate of recurrence within one year (OR, 43.0; 95% CI, 4.78-386.68; p<0.01). CONCLUSIONS: Of patients with LABCC, those with non-SCC tumors ≥8cm in size were at high risk for early central-only recurrence after cisplatin-based chemoradiation, and represent the subset of patients for whom AHR is beneficial.

Risk of metastatic ovarian involvement in nongynecologic malignancies.

OBJECTIVE: The objectives were to evaluate the risk of malignant adnexal tumors in women with nongynecologic malignancies and to identify variables associated with the risk of malignant adnexal tumors. METHODS: The eligibility criteria included the diagnosis of a nongynecologic malignancy and adnexal tumors, which were resected or subjected to biopsy at our institute between 1999 and 2010. The risk of malignant adnexal tumors was assessed by dividing the number of patients with metastatic tumors to the adnexa or primary adnexal cancers by the total number of patients. The association of clinicopathologic variables with the risk of malignant adnexal tumors was evaluated using the Fisher exact test and binary logistic regression analysis. In patients with metastatic tumors to the adnexa, the association of clinicopathologic variables with overall survival after adnexal surgery was examined using the log-rank test. RESULTS: In 166 patients with adnexal tumors, 41 benign tumors, 113 metastatic tumors to the adnexa, and 12 primary adnexal cancers were diagnosed. Age older than 46 years, a tumor type associated with a high risk for malignant adnexal tumors, and bilateral tumors significantly increased the risk of malignant adnexal tumors. The overall survival of the patients with stomach cancer was significantly worse than the patients with colorectal or breast cancers. CONCLUSION: One hundred twenty-five of the 166 patients with nongynecologic malignancies who had adnexal tumors managed surgically were shown to have malignant tumors, and most of the tumors were metastatic from primary sites. The risk of malignant adnexal tumors was associated with age, nongynecologic malignancy, and bilaterality.

Randomized clinical trial of weekly vs. triweekly cisplatin-based chemotherapy concurrent with radiotherapy in the treatment of locally advanced cervical cancer.

PURPOSE: To compare compliance, toxicity, and outcome of weekly and triweekly cisplatin administration concurrent with radiotherapy in locally advanced cervical cancer. METHODS AND MATERIALS: In this open-label, randomized trial, 104 patients with histologically proven Stage IIB-IVA cervical cancer were randomly assigned by a computer-generated procedure to weekly (weekly cisplatin 40 mg/m(2), six cycles) and triweekly (cisplatin 75 mg/m(2) every 3 weeks, three cycles) chemotherapy arms during concurrent radiotherapy. The difference of compliance and the toxicity profiles between the two arms were investigated, and the overall survival rate was analyzed after 5 years. RESULTS: All patients tolerated both treatments very well, with a high completion rate of scheduled chemotherapy cycles. There was no statistically significant difference in compliance between the two arms (86.3% in the weekly arm, 92.5% in the triweekly arm, p > 0.05). Grade 3-4 neutropenia was more frequent in the weekly arm (39.2%) than in the triweekly arm (22.6%) (p = 0.03). The overall 5-year survival rate was significantly higher in the triweekly arm (88.7%) than in the weekly arm (66.5%) (hazard ratio 0.375; 95% confidence interval 0.154-0.914; p = 0.03). CONCLUSIONS: Triweekly cisplatin 75-mg/m(2) chemotherapy concurrent with radiotherapy is more effective and feasible than the conventional weekly cisplatin 40-mg/m(2) regimen and may be a strong candidate for the optimal cisplatin dose and dosing schedule in the treatment of locally advanced cervical cancer.

Is adjuvant chemoradiotherapy overtreatment in cervical cancer patients with intermediate risk factors?

PURPOSE: To determine whether adjuvant chemoradiotherapy (CRT) improves the outcome of cervical cancer patients with intermediate risk factors. METHODS AND MATERIALS: Between January 2000 and June 2006, the medical records of 735 patients who had undergone radical surgery for Stage IB-IIA cervical cancer were reviewed retrospectively. Of the 735 patients, 172 with two or more intermediate risk factors (i.e., lymphovascular space involvement, deep stromal invasion, and tumor size≥2 cm) were grouped as follows according to the adjuvant treatment received: 34 patients, no further treatment; 49 patients, RT; and 89 patients, CRT. The significance of the clinical parameters and recurrence-free survival of each group were analyzed. RESULTS: Of the 172 patients with any of the intermediate risk factors, 137 (79.6%) had two or more intermediate risk factors. Of the 172 patients, 12 developed recurrences (6.4%)->(7.0%), with 6 in the pelvis and 6 in distant sites. All 12 recurrences occurred in those who had two or more intermediate risk factors (sensitivity, 100%); however, only six recurrences were detected in patients who met the Gynecologic Oncology Group criteria for the intermediate-risk group (sensitivity, 50%; Z test, p<.05). A statistically significant difference was found in the 3-year recurrence-free survival rate among the no further treatment, RT, and CRT groups (67.5%, 90.5%, and 97.5%, respectively; p<.05). The incidence of Grade 3-4 hematologic and gastrointestinal toxicities was not significantly different statistically between the RT and CRT groups (6.1% and 13.4%, respectively; p > .05). CONCLUSION: Postoperative adjuvant CRT can improve the outcome of cervical cancer patients with intermediate risk factors, with low increase in toxicity.

Nomogram prediction of overall survival after curative irradiation for uterine cervical cancer.

PURPOSE: The purpose of this study was to develop a nomogram capable of predicting the probability of 5-year survival after radical radiotherapy (RT) without chemotherapy for uterine cervical cancer. METHODS AND MATERIALS: We retrospectively analyzed 549 patients that underwent radical RT for uterine cervical cancer between March 1994 and April 2002 at our institution. Multivariate analysis using Cox proportional hazards regression was performed and this Cox model was used as the basis for the devised nomogram. The model was internally validated for discrimination and calibration by bootstrap resampling. RESULTS: By multivariate regression analysis, the model showed that age, hemoglobin level before RT, Fédération Internationale de Gynécologie Obstétrique (FIGO) stage, maximal tumor diameter, lymph node status, and RT dose at Point A significantly predicted overall survival. The survival prediction model demonstrated good calibration and discrimination. The bootstrap-corrected concordance index was 0.67. The predictive ability of the nomogram proved to be superior to FIGO stage (p=0.01). CONCLUSIONS: The devised nomogram offers a significantly better level of discrimination than the FIGO staging system. In particular, it improves predictions of survival probability and could be useful for counseling patients, choosing treatment modalities and schedules, and designing clinical trials. However, before this nomogram is used clinically, it should be externally validated.

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 ((18)F-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 (18)F-FDG PET scan. The feasibility of (18)F-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 (18)F-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 (18)F-FDG PET for detecting recurrences in patients with endometrial cancer were 100%, 88%, 59% and 100%, respectively. In conclusion, (18)F-FDG PET may be a useful method for the post-therapy surveillance in patients with endometrial cancer.

Adenocarcinoma arising from the respiratory ciliated epithelium in a benign cystic teratoma of the ovary.

Benign cystic teratoma of the ovary (BCTO) is the most common benign ovarian tumor, accounting for 15-20% of all ovarian tumors. It is usually diagnosed in the third and fourth decades of life. Malignant transformation is rare, occurring in approximately 1-2% of reported cases, with squamous cell carcinoma being the most common form. Adenocarcinoma arising from mature cystic teratoma is extremely rare. We present the patient with a BCTO, where a malignant transformation of respiratory ciliated epithelium resulted in well differentiated adenocarcinoma. Although respiratory epithelium is often found in BCTOs, adenocarcinoma arising from this cell type is uncommon. To our knowledge, this is the fourth reported case of adenocarcinoma arising from the respiratory epithelium of a BCTO.

Image-guided stereotactic body radiation therapy in patients with isolated para-aortic lymph node metastases from uterine cervical and corpus cancer.

PURPOSE: The aims of this study were to evaluate the role of stereotactic body radiation therapy (SBRT) as a local treatment for isolated para-aortic lymph node (PALN) metastases originating from uterine cervical and corpus cancer. METHODS AND MATERIALS: We retrospectively enrolled 30 patients with isolated PALN metastases originating from uterine cervical and corpus cancer who had received SBRT using the CyberKnife (CK). All patients were shown to have isolated PALN metastases by computed tomography (CT) and/or positron emission tomography (PET)-CT. The overall survival (OS), local control (LC) rate, and disease progression-free survival (DPFS) rate were calculated according to the Kaplan-Meier method. Comparison between prognosis groups was performed using log-rank analysis. Toxicities were also evaluated. RESULTS: The 4-year OS rate was 50.1%, and the median survival time was not reached. The OS rate among symptomatic patients was significantly lower than that among asymptomatic patients (p = 0.002). The 4-year actuarial LC rate was 67.4%. Patients with a planning target volume of