Multimodality therapy in uterine sarcoma

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.ope

Expression pattern of Aromatase Cytochrome P450 in Adenomyosis

Objective: To determine whether local estrogen production takes place in adenomyosis and in normal endometrium. Methods: The study included 23 cases of adenomyosis and 17 cases of normal uterine endometrium obtained through hysterectomy or curettage at Kangnam Cha Hospital. The frozen tissue specimens were examined by immunohistochemistry using P450 arom. Results: P450 arom was immunolocalized exclusively in the cytoplasm of glandular cells of adenomyotic tissue. However, no apparent staining was observed in stromal cells. Aromatase was expressed in the ectopic glands (82.6%), but also in the eutopic endometrium of patients with adenomyosis (23.5%). In the case of normal endometrium, P450arom was not detected. Conclusion: These results suggest that the aromatase activity is correlated to the pathophysiology of adenomyosis.ope

Leiomyoma of the female urethra and bladder: 5 cases and review of the Literature

Objective: Leiomyomas of the bladder and urethra in women is very rare. We present five cases of histologically proven the female urethral and bladder leiomyomas identified over a 15-years period at our institution, together with review of the literature focused on the symptom and proper management. Methods: Five women pathologically confirmed bladder or urethral leiomyoma were reviewed by the medical record, retrospectively. Results: One patient with bladder leiomyoma was asymptomatic, but four patients with urethral leiomyoma had a palpable mass on physical examination. The leiomyomas posited laterally were less symptomatic than other leiomyomas posited medially, and the symptoms were especially obstructive ones. All of them were removed by excision, and any complication or recurrence was not occurred. Conclusion: Leiomyomas of the bladder and urethra are rare and associated with variable symptoms depending on their locations and sizes. It is not necessary immediate operation except to excessive bleeding or acute complete obstruction. Complete excision followed by histological examination is the most reliable means of distinguishing leiomyoma from other more common and usually malignant tumors of the genitourinary tract.ope

Comparison of anti-gamma hemoglobin antibody and CD71 antibodies in isolation of fetal nucleated erythrocytes from maternal blood

Objective: In an attempt to further maximize the potential of genetic analysis from fetal cells isolation, fetal nucleated red blood cell (FNRBC) recovery with direct anti-gamma hemoglobin staining after density gradient and depletion was compared with three different whole blood magnetic separations (1-step and 2-step ferrofluid, 2-step Dynal beads). Methods: In model systems such as quantitatively defined spikes of fetal into adult blood, as well as blood samples after surgical termination procedures, fetal cell yield and purity through the results of fluorescence in situ hybridization (FISH), quantitative real time polymerase chain reaction (PCR), and fluorescence-activated cell sorting (FACS) were calculated. Results: The yield of total number of cells with a XY signal after FISH was the highest on direct anti-gamma hemoglobin staining. After normalizing the results of each experiment to the corresponding result from anti-gamma hemoglobin staining (1), ratio is 0.42 in 1-step ferrofluid, 0.33 in 2-step ferrofluid, and 0.76 in 2-step dynal beads. The fetal cell purity is clearly better in direct anti-gamma hemoglobin staining than those of the magnetic separations from whole blood. The median ratio is 56.3% in anti-gamma hemoglobin staining, 7.7% in 1-step ferrofluid, 6.5% in 2-step ferrofluid, and 31.4% in 2-step dynal beads. Conclusion: This study shows that the direct anti-gamma staining is the best fetal cell recovery system and it is very useful to isolate fetal nucleated red blood cells as a non-invasive genetic source.ope

A Case of Malignant Mixed Mullerian Tumor of the Fallopian Tube

Malignant mixed mullerain tumors (MMMT) are rare neoplasms of the female genital tract that histolotically consist of malignant epithelial and stromal components, arising in the endometirum, followed in decreasing order by the vagina, cervix, and ovary. Tubal origin is extremely rare and accounts for less than 4% of all MMMTs. Most of the patients present with nonspecific abdominal pain or abnormal vaginal bleeding. Nonspecific findings on imaging studies also make exact preoperative diagnosis very difficult, mostly mistaken as ovarian malignancies. The primary goal of treatment is removal of tumor mass by cytoreductive surgery. Postoperatively, chemotherapy or radiotherapy is added, but prognosis is very poor. The best form of postoperative adjuvant therapy is not yet established due to the rarity of this disease entity. We report a case of a malignant mixed mullerian tumor of the fallopian tube that we have experienced recently with a brief review of the literature.ope

Squamous cell carcinoma arising from mature cystic teratoma of the ovary: A clinicopathologic analysis

Objective: The aim of this study was to evaluate clinicopathologic characteristics of squamous cell carcinoma arising from ovarian mature cystic teratoma and to determine whether SCC Ag and CA 125 are useful serum markers for diagnosing this tumor. Methods: From January 1990 to December 2005, 1266 patients diagnosed with ovarian mature cystic teratoma were reviewed. Of the 1266 patients, 8 patients which had squamous cell carcinoma arising from mature cystic teratoma were evaluated in this study. A retrospective analysis of clinicopathologic characteristics and disease-free survival rate was performed. Results: The incidence of squamous cell carcinoma arising from ovarian mature cystic teratoma was 0.7% (8/1266). The mean age of the patients was 47.3 years (range, 32-72 years). Five patients (62.5%) had clinical FIGO stage I disease and three patients (37.5%) had stage III disease. The mean tumor diameter was 13.3㎝. The mean SCC Ag level was 0.3 ng/mL which was normal and the mean CA 125 was slightly increased to 68.5 U/mL. The mean disease free survival was 58.4 months and 2-year disease-free survival was 62.5% (5/8). Out of 8 patients, one patient died and one out of 7 patients who survived had recurrence. Age, clinical FIGO stage, grade, residual tumor, postoperative treatment were not significant prognostic factor for disease- free survival. Conclusion: The incidence of squamous cell carcinoma arising from ovarian mature cystic teratoma in our institute was lower and survival rate was relatively higher compared to previous studies. SCC Ag and CA 125 were not helpful tumor markers in diagnosing squamous cell carcinoma arising from ovarian mature cystic teratoma. Age, grade, residual tumor, postoperative treatment were not significant prognostic factor for disease-free survival.ope

Prognostic Significance of Flow Cytometric Nuclear DNA Quantification in Ovarian Tumors

Objective: The aim of this study was to investigate the relationship of DNA ploidy, SPF to other surgicopathologic factors including stage, grade and CA-125 in ovarian cancer and to evaluate the association between CA-125, DNA ploidy, SPF and 2-year survival in ovarian cancer. Methods: The study was prospective, which included 56 patients with ovarian tumors who were treated at the Department of Obstetrics and Gynecology, Yonsei University College of Medicine from Feb. 2000 to Jan. 2003. There were 7 benign tumors, 9 borderline tumors and 40 malignant tumors. All patients underwent surgical operation for fresh tissue. 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. DNA ploidy and S-phase fraction (SPF) were analyzed by flow cytometry in fresh surgicalspecimens from primary ovarian tumor. CA-125 was measured at diagnosis and after 6th courses of chemotherapy. Results: Of the Benign tumors, 85.7% were diploidy, 14.3% were aneuploidy. Of the borderline tumors, 88.9% were diploidy, 11.1% were aneuploidy, 60.0% of malignant tumors were diploidy, 40.0% were aneuploidy. In relation between grade and DNA quantification, grade was not significantly associated with DNA ploidy (p=0.07), SPF (p=0.08). In the relationship of stage to DNA quantification, aneuploidy was associated with advanced stage (p=0.2), mean value of SPF was significantly high in advanced stage (stage III+IV) (p=0.04). In the DNA ploidy and SPF, mean value of SPF was 5.5 +/- 4.6% in diploidy and 13.6 +/- 12.8% in aneuploidy. The difference was significant (p=0.03). The serum CA-125 level after six courses was divided into two groups with a CA-12535 U/mL, aneuploidy and mean value of SPF were increased significantly in CA-125>35 U/mL (p=0.05, 0.04). In 2-year survival, CA-125>35 U/mL, aneuploidy and SPF>10% were poor prognostic parameters. Conclusion: CA-125 is an important prognostic factor in ovarian cancer. Our results were consistent with the concept that aneuploidy or high percentage of SPF could predict the poor prognosis of disease course. The flow cytometric DNA quantification in ovarian cancer may provide major information about tumor prognosis.ope

Effect of anemia on disease free survival of cervical cancer patients treated with concurrent chemoradiotherapy

Objective: Many studies suggested the negative impact of anemia on cervical cancer patients who were treated with radiotherapy. However during the past several years, concurrent chemoradiotherapy was recognized as the standard therapy of locally advanced cervical cancer. The purpose of study was to evaluate the effect of anemia on disease free survival in cervical cancer patients with concurrent chemoradiotherapy. Methods: 116 patients were selected, who were diagnosed as cervical cancer at Yonsei University Medical Center from October 1998 to June 2003 and treated with concurrent chemoradiotherapy. Medical record was retrospectively reviewed for patient characteristics, hemoglobin, hematocrit and disease free survival. Disease free survival was analysed by univariate analysis, multivariate analysis and Kaplan-Meier method. Patients with hemoglobin value under 10 g/dL, hematocrit value under 30% were considered anemic. Results: After mean follow up duration of 27 months, among 116 patients, 26 patients experienced recurrence or progression and 10 of these patients died. Univariate and multivariate analysis reveals that stage (P=0.00, P=0.03), lesion size (P=0.01, P=0.01) and the 6th cycle hematocrit (P=0.01, P=0.01) were determinants of disease free survival. Conclusion: In cervical cancer patients treated with concurrent chemoradiotherapy, initial hemoglobin level was not related to the prognosis. However the higher stage, greater lesion size, and lower level of 6th cycle hematocrit were related to the poor prognosis.ope

Prognostic Value of Nuclear DNA Quantification and Cyclin A in Epithelial Ovarian Cancer

Objective: This study was carried out to investigate the relationship between DNA ploidy, S-phase fraction (SPF), expression of cyclin A and clinical prognostic factors including stage, grade, CA-125 and residual tumor size in epithelial ovarian cancer, and to evaluate the association between DNA ploidy, SPF, expression of cyclin A and 3-year survival. Methods: Study group consisted of 31 cases of epithelial ovarian cancer, 10 of borderline ovarian tumor and 5 of benign ovarian tumor diagnosed at the department of Obstet. and Gynecol. in Yonsei University College of Medicine, Seoul, Korea from Feb. 2000 to Jan. 2003. All patients underwent staging-laparotomy and postoperative chemotherapy. The level of CA-125 was assessed after 6th postoperative chemotherapy with cut-off value of 35 U/mL. DNA ploidy and SPF were evaluated by flow-cytometry of fresh ovarian tissue obtained at the operative field. The expression of cyclin A was evaluated by immuno-histochemical stain. Expression of 5% was considered as positive. Statistical analysis was done by two-sample t-test, chi-square test, and Kaplan-Meier survival curve using SPSS ver 11.0 software. Results: In 46 ovarian tumors aneuploidy, SPF and expression of cyclin A were significantly higher in epithelial ovarian cancer as compared with benign and borderline tumors (p=0.004, 0.001, 0.001, respectively). Number of aneuploidy, SPF and expression of cyclin A were significantly higher in patients with higher grade, more advanced stage, higher level of CA-125 (more than 35 U/mL) and more than 2 cm of residual tumor size (p=0.004, 0.009, 0.05, 0.002 in aneuploidy; p=0.06, 0.01, 0.04, 0.007 in SPF; p=0.03, 0.004, 0.06, 0.02 in cyclin A). Aneuploidy and expressions of more than 10% of SPF and cyclin A were also associated with poorer overall survival (p=0.02, 0.02, <0.0001, respectively). Significantly positive correlations were observed among these factors. Conclusion: Number of aneuploidy, percentage of SPF and expression of cyclin A were higher in more advanced stage, higher grade, higher CA-125 and more than 2 cm of residual tumor size and associated with poorer overall survival. Thus DNA flow-cytometry and estimation of expression of cyclin A may provide major information about prognosis of disease in epithelial ovarian cancer patients.ope

Robot-assisted total laparoscopic hysterectomy: initial experience in Korea

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.ope